Cholelithiasis prevalence and risk factors in individuals with severe or profound intellectual and motor disabilities

BACKGROUND

The prevalence and risk factors of cholelithiasis in individuals with severe or profound intellectual and motor disabilities (SPIMD) are poorly characterised. Thus, we aimed to investigate the prevalence and risk determinants of cholelithiasis in a cohort with SPIMD under medical care in a residential facility.

METHODS

We categorised 84 patients in a residential hospital for persons with SPIMD into groups: those with (Group CL) and without (Group N) cholelithiasis. Gallstones were detected via computed tomography, ultrasonography or both. We evaluated gastrostomy status, nutritional and respiratory support, constipation, and bladder and kidney stones. Data were significantly analysed using univariate and multivariate logistic regression analyses.

RESULTS

The prevalence rate of cholelithiasis in our SPIMD cohort was 27%. There were no significant differences in sex, age, weight, height, or Gross Motor Function Classification System between the two groups. However, more patients received enteral nutrition (39.13% vs. 6.56%; P = 0.000751) and were on ventilator support (56.52% vs. 19.67%; P = 0.00249) in Group CL than in Group N. Enteral nutrition [odds ratio (OR) 10.4, 95% confidence interval (CI) 1.98-54.7] and ventilator support (OR 20.0, 95% CI 1.99-201.0) were identified as independent risk factors for the prevalence of cholelithiasis in patients with SPIMD.

CONCLUSIONS

Patients with SPIMD demonstrated an increased prevalence of cholelithiasis, with a notable association between nutritional tonic use and respiratory support. Therefore, to emphasise the need for proactive screening, it is crucial to devise diagnostic and therapeutic strategies specific to patients with SPIMD. Further investigation is essential to validate our findings and explore causative factors.

Atypical presentation of tight filum terminale with thoracic disc herniation: a case report

BACKGROUND

Tight filum terminale is a rare and challenging condition to diagnose because it presents with nonspecific symptoms and unclear imaging findings. This report documents an atypical case of tight filum terminale.

CASE PRESENTATION

The patient was a previously healthy Asian 18-year-old male presenting with recurrent upper extremity and back pain, initially treated as nonspecific musculoskeletal pain. Notably, the patient's symptoms were inconsistent with the dermatome, showing no correlation with his skin's sensory innervation areas. In contrast to typical tight filum terminale presentations focused on lower extremity and lumbar region disturbances, this patient experienced pain and weakness predominantly in the upper extremities and back, hypothesized to result from traction myelopathy exacerbated by thoracic disc herniation. Investigations including blood and nerve function tests were inconclusive. However, a magnetic resonance imaging scan revealed a combination of tight filum terminale and tiny thoracic disc herniation. A diagnosis of tethered spinal cord syndrome was confirmed following further tests and imaging. The filum terminale was surgically removed, resolving the symptoms at a 7-month follow-up.

CONCLUSIONS

This case underlines the importance of including tight filum terminale as a differential diagnosis in cases of unexplained upper or lower extremity pain. Primary care practitioners, particularly those managing undefined symptoms, should consider tight filum terminale in their diagnostic approach.

Web-Based Search Volume for HIV Tests and HIV-Testing Preferences During the COVID-19 Pandemic in Japan: Infodemiology Study

BACKGROUND

Research has found a COVID-19 pandemic-related impact on HIV medical services, including clinic visits, testing, and antiviral therapy initiation in countries including Japan. However, the change in trend for HIV/AIDS testing during the COVID-19 pandemic has not been explored extensively in the Japanese population.

OBJECTIVE

This infodemiology study examines the web-based search interest for two types of HIV tests, self-test kits and facility-based tests, before and during the COVID-19 pandemic in Japan.

METHODS

The monthly search volume of queried search terms was obtained from Yahoo! JAPAN. Search volumes for the following terms were collected from November 2017 to October 2018: "HIV test," "HIV test kit," and "HIV test health center." The search term "Corona PCR" and the number of new COVID-19 cases by month were used as a control for the search trends. The number of new HIV cases in the corresponding study period was obtained from the AIDS Trend Committee Quarterly Report from the AIDS Prevention Foundation.

RESULTS

Compared to the search volume of "corona-PCR," which roughly fluctuated corresponding to the number of new COVID-19 cases in Japan, the search volume of "HIV test" was relatively stable from 2019 to 2022. When we further stratified by the type of HIV test, the respective web-based search interest in HIV self-testing and facility-based testing showed distinct patterns from 2018 to 2022. While the search volume of "HIV test kit" remained stable, that of "HIV test health center" displayed a decreasing trend starting in 2018 and has remained low since the beginning of the COVID-19 pandemic. Around 66%-71% of the search volume of "HIV test kits" was attributable to searches made by male internet users from 2018 to 2022, and the top three contributing age groups were those aged 30-39 (27%-32%), 20-29 (19%-32%), and 40-49 (19%-25%) years. On the other hand, the search volume of "HIV test health centers" by male users decreased from more than 500 from 2018 to 2019 to fewer than 300 from 2020 to 2022.

CONCLUSIONS

Our study found a notable decrease in the search volume of "HIV test health center" during the pandemic, while the search volume for HIV self-testing kits remained stable before and during the COVID-19 crisis in Japan. This suggests that the previously reported COVID-19-related decrease in the number of HIV tests mostly likely referred to facility-based testing. This sheds light on the change in HIV-testing preferences in Japan, calling for a more comprehensive application and regulatory acceptance of HIV self-instructed tests.

Participation of medical students in the medical team of sports events

Including medical student volunteers in the medical team for the triathlon strengthens the medical team structure, and encourages medical students to involve in sports medicine. Family physicians who play a role in the medical team for sports events can adopt medical students as a member and can educate them.

Intravenous vagal stimulation catheter, JOHAKU, rapidly decreases heart rate and myocardial oxygen consumption without worsening hemodynamics

Background

Rapid reduction of heart rate (HR) is the most evident physiological response of vagal nerve stimulation (VNS). Since HR reduction is the most potent factor to decrease myocardial oxygen consumption rate (MVO2), the appropriate VNS can exert cardio-protective effects. It is also known that VNS reduces inflammation, oxidative stress, and sympathetic overload. In addition, the VNS during ischemia-reperfusion is known to attenuate myocardial damage by studies in various animal species. Despite the presence of preclinical evidence of VNS benefits, the lack of the device has limited the translation of this technology to clinical practice. We have recently developed an intravenous VNS catheter (JOHAKU, Neuroceuticals Inc.) that can stimulate the right vagal nerve via superior vena cava (SVC) (Figure 1) on temporary basis.

Purpose

We aimed to confirm the feasibility of JOHAKU as a device to modulate heart rate and MVO2 rapidly by a canine experiment.

Methods

In eight beagle dogs, JOHAKU was inserted from the right femoral vein and placed at the SVC level. The stimulation intensity was adjusted to 10–20 V (20 Hz). We simultaneously recorded electrocardiogram and intraarterial blood pressure (BP). In three of eight dogs, we measured the left anterior descending coronary artery flow and oxygen saturations of arterial and coronary sinus blood to calculate MVO2. We compared HR, BP, and MVO2 during JOHAKU stimulation to ones at baseline.

Results

As shown in Figure 2, JOHAKU attenuated HR immediately after stimulation. Compared with baseline, JOHAKU significantly reduced HR (baseline: 135±13 vs. 5 min on stimulation: 107±13 bpm, p<0.05), and did not affect mean BP significantly (96.2±22.8 vs. 89.4±26.6 mmHg, P=0.59). HR promptly recovered to baseline level after JOHAKU stopped. JOHAKU also reduced MVO2 (0.57±0.43 vs. 0.48±0.38 ml/min, p<0.05).

Conclusion

JOHAKU rapidly attenuated cardiac metabolism burden via the rapid HR reduction. The controllability of HR by JOHAKU without affecting BP enables us to apply the VNS even for patients with hemodynamic instability, such as heart failure and acute myocardial infarction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical and Research Development

Mice with cleavage-resistant N-cadherin exhibit synapse anomaly in the hippocampus and outperformance in spatial learning tasks

N-cadherin is a homophilic cell adhesion molecule that stabilizes excitatory synapses, by connecting pre- and post-synaptic termini. Upon NMDA receptor (NMDAR) activation by glutamate, membrane-proximal domains of N-cadherin are cleaved serially by a-disintegrin-and-metalloprotease 10 (ADAM10) and then presenilin 1(PS1, catalytic subunit of the γ-secretase complex). To assess the physiological significance of the initial N-cadherin cleavage, we engineer the mouse genome to create a knock-in allele with tandem missense mutations in the mouse N-cadherin/Cadherin-2 gene (Cdh2 R714G, I715D, or GD) that confers resistance on proteolysis by ADAM10 (GD mice). GD mice showed a better performance in the radial maze test, with significantly less revisiting errors after intervals of 30 and 300 s than WT, and a tendency for enhanced freezing in fear conditioning. Interestingly, GD mice reveal higher complexity in the tufts of thorny excrescence in the CA3 region of the hippocampus. Fine morphometry with serial section transmission electron microscopy (ssTEM) and three-dimensional (3D) reconstruction reveals significantly higher synaptic density, significantly smaller PSD area, and normal dendritic spine volume in GD mice. This knock-in mouse has provided in vivo evidence that ADAM10-mediated cleavage is a critical step in N-cadherin shedding and degradation and involved in the structure and function of glutamatergic synapses, which affect the memory function.

Effective reflection distance and its association with pressure augmentation index under a variety of acute hemodynamic perturbation

 

Effective reflection distance (ERD), a conceptual distance to a major reflection site from the aortic root, is associated with aging and pressure augmentation index (AIx) in clinical population. However, it is poorly understood how ERD varies and associates with AIx within a subject when the hemodynamic condition is changed extensively by acute pharmacological interventions.

Methods

In 13 anesthetized dogs, we measured aortic pressure (AP) and flow (AF) and femoral arterial flow (FF). Using AP, AF and FF, ERD based on an arterial model comprising a tube with frequency-dependent load (ERD_TL) was determined as a physiologically valid reference. ERD was also determined by wave separation (ERD_WSA) and pressure-only analyses (ERD_AW). Hemodynamic condition was changed by administrating zatebradine (bradycardic agent), nitroprusside, noradrenaline, dobutamine, and dextran.

Results

ERD_TL shortened significantly in response to infusion of nitroprusside or dobutamine. ERD_TL was significantly and negatively associated with AIx in multivariate analysis (Figure/Table). Changes in ERD_WSA or ERD_AW, and their association with AIx were not necessarily concordant with those observed in ERD_TL.

Conclusion

For the first time, we demonstrated that under diverse hemodynamic conditions, ERD_TL can change sensitively, and associates with AIx physiologically. This substantiates importance of tight attention to medication at clinical analysis of wave reflection phenomena. ERD_WSA or ERD_AW may not be a surrogate of ERD_TL.

Responses of ERD to drugs

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science (JSPS)

Donepezil markedly prevents the progression of chronic heart failure and renal dysfunction in renal artery stenosis-induced hypertensive rats

Introduction

Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension.

Methods

RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). In the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology.

Results

Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05) and kidney fibrosis (left: −64%, P<0.001; right: −55%, P<0.01). DT also significantly prevented the progression of CHF, through suppressing cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac fibrosis (−70%, P<0.01), and cardiac dysfunction [cardiac index: 102±3 vs. 86±3 ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05), BNP (360±13 vs. 460±39 pg/ml, P<0.05), angiotensin II and aldosteron, and suppressed the systemic inflammation.

Conclusions

Donepezil treatment markedly prevented the progression of CHF and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension.

Funding Acknowledgement

Type of funding source: None

A minimally-occlusive cuff method utilizing ultrasound vascular imaging for stress-free blood pressure measurement

Objective

Occlusive cuff inflation in ambulatory blood pressure (BP) monitoring disturbs the daily life of the user, and affects efficacy of monitoring. To overcome this limitation, we have developed a novel minimally-occlusive cuff method for stress-free measurement of BP. This study aimed to experimentally evaluate the reliability of this method, and improve the precision of this method by implementing a machine learning algorithm.

Methods

In this method, a thin-plate-type ultrasound probe (Size: 5.6mm-thickness × 28mm × 26mm; weight: 10g) is placed between the cuff and the skin, and used to measure the ultrasonic dimension of the artery (Figure 1). The cuff pressure (Pc), arterial dimension at systole (Ds) and diastole (Dd), systolic BP (SBP) and diastolic BP (DBP) during cuff inflation are theoretically related by the following equations,

SBP-Pc = P0·Exp[α·Ds]

DBP-Pc = P0·Exp[α·Dd]

Where P0 and α are constants, and α indicates arterial stiffness. Since multiple sets of the two equations can be defined over multiple cardiac beats while measuring Pc, Ds and Dd during mild cuff inflation (Pc is controlled less than 50 mmHg, Figure 1), it is possible to estimate SBP (SBPe) and DBP (DBPe) as solutions of the equations. In 6 anesthetized dogs, we attached the cuff and the probe to the right thigh to get SBPe and DBPe, which were one-time calibrated in each animal against reference SBP and DBP measured by using an intra-arterial catheter. We also determined the pulse arrival time (PAT), which is a commonly employed parameter in cuff-less BP monitoring. In all the dogs, BP was changed extensively by infusing noradrenaline or sodium nitroprusside.

Results

DBPe correlated tightly with DBP with a coefficient of determination (R2) of 0.85±0.08, and predicted DBP with error of 3.9±7.9 mmHg after one-time calibration (Figure 2). PAT correlated poorly with DBP (R2=0.49±0.17), and predicted DBP less accurately than this method. SBPe correlated well with SBP (R2=0.78±0.08) (Figure 3). However, even after one-time calibration, difference between SBPe and SBP was 2.6±18.9 mmHg, which was not acceptable. To improve the precision in SBP prediction, we used supervised machine learning approach with use of a support vector algorithm (Python, Scikit-learn), which regressed feature variables (SBPe, DBPe, Ds, Dd heart rate, and PAT) against teacher signal (reference SBP). The support vector algorithm, once trained, predicted SBP with acceptable accuracy with error of 0.7±6.9 mmHg (Figure 3).

Conclusions

This method reliably tracks BP changes without occlusive cuff inflation. Once calibrated, this method measures DBP accurately. With the aid of machine learning, precision in SBP prediction was greatly improved to an acceptable level. This method with machine learning approach has potential for stress-free BP measurement in ambulatory BP monitoring.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Donepezil as a novel therapy for suppressing the progression of cardiovascular remodeling in obesity-induced hypertensive rats with reperfused myocardial infarction

Introduction

Acetylcholinesterase inhibition by donepezil has been shown to improve long-term survival in permanent myocardial infarction (MI)-induced chronic heart failure rats. This study examined whether donepezil is applicable to the treatment of obesity-induced hypertension with reperfused MI (RMI).

Methods

Four-week-old SD rats were fed a high-fat diet (57% kcal as fat) for 15 weeks. We implanted a blood pressure (BP) telemetry into the animals (8-week-old) for monitoring artery pressure. After a 1-week recovery, RMI was created by occluding the left coronary artery (30min) followed by reperfusion. Surviving animals were randomly assigned to untreated (UT, n=16) or donepezil treated (DT, n=16, 3 mg/kg/day) group. After a 10-week treatment, the effects of donepezil were evaluated by hemodynamics, blood biomarkers, immunohistochemistry, and morphology.

Results

The high-fat diet caused obesity and hypertension (9-week-old: systolic BP = 134±4 mmHg; diastolic BP = 92±2 mmHg) in the normal rats. Compared with UT, DT significantly decreased the heart rate (296±5 vs. 318±8 bpm, P<0.05). DT significantly prevented the progression of cardiac remodeling and dysfunction [cardiac index: 91±4 vs. 73±9 ml/min/kg, P<0.01; left ventricular (LV) end-diastolic pressure: 11±1 vs. 20±2 mmHg, P<0.01; LV dp/dt max: 5347±206 vs. 3637±433 mmHg/sec, P<0.01], through increasing capillary density (+120%/field, P<0.001), reducing cardiac fibrosis (−50%, P<0.01) and myocardial infarcted area (17±2 vs. 24±2%, P<0.05), suppressing cardiac hypertrophy (2.35±0.04 vs. 2.70±0.14 g/kg, P<0.01) and coronary artery remodeling (wall thickness: 30±1 vs. 37±2 mm, P<0.01; media-to-lumen ratio: 2.3±0.2 vs. 6.2±1.6, P<0.001). Additionally, DT not only decreased plasma levels of insulin, norepinephrine, BNP, angiotensin II, but also improved the systemic inflammation.

Conclusions

Donepezil treatment significantly suppressed the progression of cardiovascular remodeling and dysfunction following RMI in obesity-induced hypertensive rats, suggesting that donepezil may be used as a potential candidate for post-RMI therapy in obesity-induced hypertensive patients.

Funding Acknowledgement

Type of funding source: None

P105 Chronic vagal nerve stimulation suppress thirst through decreasing vasopressin secretion in the rats with chronic heart failure

Introduction

Chronic right cervical vagal nerve electric stimulation (VS) exerted prognostic benefits in heart failure rats. Exploring the mechanism is significant for clinical application. This study examined the effect of VS on arginine vasopressin (AVP) secretion and drinking behavior in the rats with chronic heart failure.

Methods

After a week recovery of myocardial infarction (MI), surviving rats after were randomly instrumented to VS group and sham stimulation (SS) group. A drop sensor was used to record real-time fluid consumption. Blood samples were collected weekly from the 3rd week during the 6 weeks treatment.

Results

Vagal stimulation did not change the daily fluid consumption (Mean ± SE, 76.2 ± 1.1 vs. 77.8 ± 2.1 ml/kg/day, n = 6, P < 0.05). Thirst, which is defined as per drinking volume (PDV), significantly increased during the early weeks after MI (Fig A), while VS significantly suppressed PDV (Fig B is the data of 6th week) by increasing the drinking intervals. The level of plasma AVP was increased to about 2 fold during 6 weeks observation in the SS group, however, VS suppressed this upregulation (Fig C).

Conclusion

These results suggest that VS may activate vagal afferent components which related to inhibition of AVP secretion and then suppressed the augmentation of thirst. Frequent drinking small volume may benefit for homeostasis in CHF.

Abstract P105 Figure. Drinking behavior and AVP

P3501Oral administration of donepezil markedly prevents the progression of chronic heart failure in renal artery stenosis-induced hypertensive rats

Introduction

Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension.

Methods

RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). At the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology.

Results

Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05). DT also significantly improved cardiac remodeling, through suppressing the progression of cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac dysfunction [cardiac index: 102±3 vs. 86±3ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), angiotensin II (17±2 vs. 23±2 pg/ml, P<0.05), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05) and BNP (360±13 vs. 460±39 pg/ml, P<0.05), and suppressed the systemic inflammation (CRP: 190±12 vs. 382±58 mg/ml, P<0.01).

Conclusions

Donepezil treatment markedly prevented the progression of cardiac remodeling and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension.

P4605Landiolol, a beta-blocker, optimizes cardiac energetics and peripheral microhemodynamics better than ivabradine while reducing heart rate at hemodynamic resuscitation of experimental septic shock

Background

Septic shock is associated with sympathetic over-activation characterized by tachycardia, which is associated with poor survival. Though several kinds of drugs are available to reduce heart rate (HR), it is not clear which drug should be used to reduce HR effectively in initial hemodynamic resuscitation in septic shock.

Purpose

The aim of this study was to experimentally investigate comparative effects of landiolol (a β-blocker) and ivabradine (an If-channel inhibitor) on initial hemodynamic resuscitation in a canine model of endotoxin shock.

Methods

We used 19 anesthetized dogs. Seven dogs were allocated to control (CT) group, six dogs to landiolol (BB) group, and six dogs to ivabradine (IVA) group. In all the groups, endotoxin shock was induced by intravenous infusion of Escherichia coli lipopolysaccharide (4 mg/kg) over 1 h. After induction of endotoxin shock, we started hemodynamic resuscitation to restore mean arterial pressure (AP) and cardiac output (CO) by infusing noradrenaline (NA) and Ringer acetate solution (RiA). Dose of NA and RiA were automatically titrated with use of a computer-controlled drug infusion system that we developed previously. Hemodynamic resuscitation was continued for 4 h. During resuscitation, the BB group was given landiolol infusion at a low-dose range (1–10 μg/kg/min, manually titrated), while the IVA group was given ivabradine at 0.25 mg/kg bolus-injected every 2 h.

Results

The drug infusion system automatically restored AP to 70 mmHg and CO to greater than 90% of baseline level in all the groups. The restored AP and CO were not significantly different among the three groups (Figure A, B). There were no significant differences in the computer-controlled infusion rate of NA and cumulated volume of RiA infused among the three groups (Figure C). During the first 2 h of resuscitation, HR was significantly reduced in the BB and IVA groups in comparison to the CT group (Figure D). However, only in the BB group, cardiac oxygen consumption was significantly lower than that in the CT group (Figure E). Blood lactate level decreased significantly after hemodynamic resuscitation only within the BB group (Figure F).

Figure 1

Conclusions

In the initial hemodynamic resuscitation of septic shock, both low-dose landiolol infusion and ivabradine injection may be used to reduce HR. However, to optimize cardiac energetics and peripheral microhemodynamics, low-dose landiolol infusion may be preferable to ivabradine injection.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant Number 15K01307, 18K12126.

Randomized clinical trial of extensive intraoperative peritoneal lavage versus standard treatment for resectable advanced gastric cancer (CCOG 1102 trial)

BACKGROUND

A survival benefit of extensive intraoperative peritoneal lavage (EIPL) has been reported in patients with gastric cancer with positive peritoneal cytology. The hypothesis of this study was that EIPL may reduce peritoneal recurrence in patients with advanced gastric cancer who undergo surgery with curative intent.

METHODS

This was an open-label, multi-institutional, randomized, phase 3 trial to assess the effects of EIPL versus standard treatment after curative gastrectomy for resectable gastric cancer of T3 status or above. The primary endpoint was disease-free survival (DFS); secondary endpoints were overall survival, peritoneal recurrence-free survival and incidence of adverse events.

RESULTS

Between July 2011 and January 2014, 314 patients were enrolled from 15 institutions and 295 patients were analysed (145 and 150 in the EIPL and no-EIPL groups respectively). The 3-year DFS rate was 63·9 (95 per cent c.i. 55·5 to 71·2) per cent in the EIPL group and 59·7 (51·3 to 67·1) per cent in the control group (hazard ratio (HR) 0·81, 95 per cent c.i. 0·57 to 1·16; P = 0·249). The 3-year overall survival rate was 75·0 (67·1 to 81·3) per cent in the EIPL group and 73·7 (65·9 to 80·1) per cent in the control group (HR 0·91, 0·60 to 1·37; P = 0·634). Peritoneal recurrence-free survival was not significantly different between the two groups (HR 0·92, 0·62 to 1·36; P = 0·676). No intraoperative complications related to EIPL were observed.

CONCLUSION

EIPL did not improve survival or peritoneal recurrence in patients who underwent gastrectomy for advanced gastric cancer. Registration number: 000005907 (http://www.umin.ac.jp/ctr/index.htm).

Changes in medication adherence and unused drugs after switching from daily dipeptidyl peptidase-4 inhibitors to once-weekly trelagliptin in patients with type 2 diabetes

AIMS

The changes in patients' satisfaction with the treatment, medication adherence and unused drugs before and after switching from daily DPP-4 inhibitors to once-weekly trelagliptin administration were prospectively investigated in patients with type 2 diabetes.

METHODS

After excluding 46 patients who declined to switch from daily DPP-4 inhibitors, 79 subjects were included in the present study. The clinical parameters and results of questionnaire surveys regarding satisfaction with treatment as well as impressions of the amount of medicine/number of doses, medication adherence, and unused drug were examined at the baseline and 3 months after switching from daily DPP-4 inhibitors to trelagliptin in 75 patients with type 2 diabetes.

RESULTS

Although the value of HbA1c did not change (7.0% ± 0.5% to 7.0% ± 0.6%), the scores representing satisfaction with the treatment (25.2 ± 6.4 to 26.4 ± 6.0), impression of the amount of medicine (-0.3 ± 1.0 to 0.3 ± 1.0) and number of doses (0.3 ± 1.0 to 0.8 ± 0.6), and medication adherence (0.8 ± 0.4 to 0.9 ± 0.3) as assessed by the questionnaire surveys were significantly improved after switching from DPP-4 inhibitors. The self-reported amount of unused drugs was significantly reduced after switching.

CONCLUSIONS

Switching from daily DPP-4 inhibitors to once-weekly trelagliptin improved the satisfaction with the treatment, impression of the prescribed medicine and medication adherence in the type 2 diabetic patients who expresses a desire to reduce their prescription medicines. In such patients, improvements in the glycemic control and long-term prognosis might be expected through the reduction of unused drugs.

A comparison of the clinical courses of type 2 diabetic patients whose basal insulin preparation was replaced from insulin glargine 100 units/mL to insulin glargine biosimilar or 300 units/mL: a propensity score-matched observation study

Objective: We compared the clinical course of type 2 diabetic patients whose basal insulin preparations were replaced from insulin glargine (IGlar) 100 units/mL (U100) to IGlar biosimilar or IGlar 300 units/mL (U300).

Methods: After propensity score matching, 34 patients whose basal insulin preparation was switched from IGlar U100 to IGlar biosimilar and 102 switched to IGlar U300 were observed for 6 months.

Results: The HbA1c level and body weight did not change significantly after the replacement in the IGlar biosimilar or IGlar U300 groups. In the IGlar biosimilar group, the frequency of subjects who experienced hypoglycemia after the replacement (12%) was not different from before (12%). However, the frequency was significantly lower after the replacement (2%) than before (13%) in the IGlar U300 group. The change in the HbA1c level after the replacement showed a significant association with the HbA1c level at the baseline but not with the kind of IGlar. Hypoglycemia was frequently observed in subjects who had experienced hypoglycemia before the replacement.

Conclusions: IGlar biosimilar and IGlar U300 induced similar HbA1c and body weight changes among type 2 diabetic patients. IGlar biosimilar is a suitable option for patients with a low risk for hypoglycemia.

Bronchial damage and diffuse alveolar hemorrhage following chlorine gas inhalation: A case report

Chlorine is a toxic inhalant and sources of exposure for individuals include accidental releases of chlorine vapor due to industrial or chemical transportation accidents. Inhalation of a large quantity of gas may cause circulatory and respiratory disorders or even mortality; however, the effects of a small amount of chlorine gas may be asymptomatic. The present case study presents a successfully treated 55-year-old male patient exposed to chlorine gas, resulting in bronchial damage and diffuse alveolar hemorrhage. Endobronchial and alveolar injuries were evaluated by direct observation using fiberoptic bronchoscopy (FB) and analyzing bronchoalveolar lavage fluid obtained by FB. Taking a precise medical history from the patient is crucial to correctly diagnose toxic gas inhalation. In addition, a timely and proper evaluation with chest imaging as well as FB may provide useful clinical information. Therefore, clinicians should consider performing FB if the circumstances permit.

Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after distal pancreatectomy. The aim of this study was to investigate whether duct-to-mucosa pancreaticogastrostomy of the pancreatic stump decreased clinical POPF formation compared with handsewn closure after distal pancreatectomy.

METHODS

This multicentre RCT was performed between April 2012 and June 2014. Patients undergoing distal pancreatectomy were assigned randomly to either duct-to-mucosa pancreaticogastrostomy or handsewn closure. The primary endpoint was the incidence of clinical POPF. Secondary endpoints were rates of other complications and length of hospital stay.

RESULTS

Some 80 patients were randomized, and 73 patients were evaluated in an intention-to-treat analysis: 36 in the pancreaticogastrostomy group and 37 in the handsewn closure group. The duration of operation was significantly longer in the pancreaticogastrostomy group than in the handsewn closure group (mean 268 versus 197 min respectively; P < 0·001). The incidence of clinical POPF did not differ between groups (7 of 36 versus 7 of 37; odds ratio (OR) 1·03, 95 per cent c.i. 0·32 to 3·10; P = 1·000). The rate of intra-abdominal fluid collection was significantly lower in the pancreaticogastrostomy group (6 of 36 versus 21 of 37; OR 0·15, 0·05 to 0·45; P < 0·001). There were no statistically significant differences in the rates of other complications or length of hospital stay.

CONCLUSION

Duct-to-mucosa pancreaticogastrostomy did not reduce the incidence of clinical POPF compared with handsewn closure of the pancreatic stump after distal pancreatectomy. Registration number UMIN000007426 (http://www.umin.ac.jp).

Clinical Value of Pet with 18F-Fluorodeoxyglucose and L-Methyl-11C-Methionine for Diagnosis of Recurrent Brain Tumor and Radiation Injury

We studied 15 patients clinically suspected to have recurrent brain tumor or radiation injury, using positron emission tomography (PET) with 18F-fluorodeoxyglucose (18FDG) and L-methyl-11C-methionine (11C-Met). PET with 11C-Met (Met-PET) clearly delineated the extent of recurrent brain tumor as focal areas of increased accumulation of 11C-Met, and was useful for early detection of recurrent brain tumor. PET with 18FDG (FDG-PET) showed focal 18FDG-hypermetabolism in one patient with malignant transformation of low grade glioma, and demonstrated its usefulness for evaluation of malignant transformation. 18FDG-hypometabolism was observed in all patients with radiation injury, but was also found in one patient with recurrent malignant brain tumor. 11C-Met uptake in 3 patients with radiation injury was similar to that of the normal cortical tissue. FDG-PET can be used to initially exclude recurrent brain tumor which is seen as 18FDG-hypermetabolism. The combined use of Met-PET in addition to FDG-PET can improve the accuracy of differentiation of recurrent brain tumor with 18FDG-hypometabolism from radiation injury.

Concurrent analysis of human equilibrative nucleoside transporter 1 and ribonucleotide reductase subunit 1 expression increases predictive value for prognosis in cholangiocarcinoma patients treated with adjuvant gemcitabine-based chemotherapy

BACKGROUND

The aim of this study was to investigate the predictive and prognostic values of intratumoural human equilibrative nucleoside transporter 1 (hENT1) and ribonucleotide reductase subunit 1 (RRM1) expression in advanced cholangiocarcinoma patients treated with adjuvant gemcitabine-based chemotherapy (AGC).

METHODS

Intratumoural hENT1 and RRM1 expression levels were investigated immunohistochemically in 127 patients with advanced cholangiocarcinoma who underwent surgical resection (68 with AGC and 59 without AGC). The impacts of hENT1 and RRM1 expression on survival were evaluated.

RESULTS

High intratumoural hENT1 and RRM1 expression levels were observed in 86 (68%) and 67 (53%) patients, respectively. In a multivariate analysis of 68 patients who received AGC, high hENT1 (P=0.044) and low RRM1 expression (P=0.009) were independently associated with prolonged disease-free survival (DFS), whereas low RRM1 expression (P=0.024) was independently associated with prolonged overall survival (OS). Moreover, concurrent high hENT1 and low RRM1 expression was a powerful independent predictor of prolonged DFS (P<0.001) and OS (P=0.001) when the combined classification of hENT1 and RRM1 was introduced.

CONCLUSIONS

Concurrent analysis of hENT1 and RRM1 expression may increase the predictive value of these biomarkers for survival of advanced cholangiocarcinoma patients treated with AGC.

Sympathetic afferent stimulation inhibits central vagal activation induced by intravenous medetomidine in rats

AIM

To examine whether sympathetic afferent stimulation (SAS) inhibits central vagal activation induced by α2 -adrenergic stimulation.

METHODS

In anaesthetized Wistar-Kyoto rats, a cardiac microdialysis technique was applied to the left ventricle, and the effect of α2 -adrenergic stimulation by medetomidine on myocardial interstitial acetylcholine (ACh) levels was examined in the absence (n = 6) or the presence (n = 6) of SAS delivered from the left stellate ganglion. The effect of electrical vagal efferent stimulation on myocardial interstitial ACh release was also examined in the absence or the presence of SAS (n = 6).

RESULTS

Intravenous medetomidine (0.1 mg kg(-1) ) significantly increased myocardial interstitial ACh levels in the absence of SAS (from 1.95 ± 0.79 to 3.36 ± 1.61 nM, P < 0.05), but not in the presence of SAS (from 1.67 ± 0.67 to 2.01 ± 0.78 nM). In contrast, electrical vagal nerve stimulation increased myocardial interstitial ACh level to the same degree regardless of SAS (from 1.66 ± 0.16 to 3.93 ± 0.72 nM without SAS vs. 4.05 ± 0.89 nM with SAS).

CONCLUSION

Sympathetic afferent stimulation inhibited medetomidine-induced ACh release, but not electrical stimulation-induced ACh release, suggesting that SAS inhibited medetomidine-induced vagal activation via central mechanisms. While central vagal activation by α2 -adrenergic agonists could be an alternative to electrical vagal activation, blocking sympathetic afferent input may be important to increase the efficacy of α2 -adrenergic agonists in enhancing vagal nerve activity.

High-frequency dominant depression of peripheral vagal control of heart rate in rats with chronic heart failure

AIM

To examine whether dynamic characteristics of the peripheral vagal control of heart rate (HR) are altered in chronic heart failure (CHF).

METHODS

The right vagal nerve was electrically stimulated according to a binary white noise signal, and the transfer function from vagal nerve stimulation (VNS) to HR was estimated in the frequency range from 0.01 to 1 Hz in five control rats and five CHF rats under anaesthetized conditions. The rate of VNS was changed among 10, 20 and 40 Hz.

RESULTS

A multiple linear regression analysis indicated that the increase in the VNS rate augmented the ratio of the high-frequency (HF) gain to the steady-state gain in the control group but not in the CHF group. As a result, the dynamic gain of the transfer function in the frequencies near 1 Hz decreased more in the CHF group than in the control group.

CONCLUSION

Changes in the dynamic characteristics of the peripheral vagal control of HR may contribute to the manifestation of decreased HF components of HR variability observed in CHF.

Primary hepatic carcinoid tumor

We report the case of primary hepatic carcinoid tumor of which diagnosis was made by fine needle biopsy of a liver mass. The patient was treated successfully by left hepatic trisegmentectomy. This patient presented with complaints of generalized fatigue, but denied the presence of flushing, diarrhea, or other endocrine symptoms. Physical examination was unremarkable. A biopsy specimen revealed Grimelius stained cells that were immunoreactive for chromogranin A. Careful pre- and intraoperative examinations revealed no other primary lesions. Argyrophilia of the tumor cells suggested that the tumor was of fore five cases of primary hepatic carcinoid tumors previously reported in the literature are also reviewed.