Association between Reduction of Muscle Mass and Faster Declines in Global Cognition among Older People: A 4-Year Prospective Cohort Study

OBJECTIVES

A few studies reported that both decrease and increase in body mass index (BMI) were associated with the development of dementia in later life. However, it is unclear what changes in body composition are associated with cognitive decline. This study investigated the longitudinal influences of changes in body composition on cognitive function among community-dwelling adults.

DESIGN, SETTING AND PARTICIPANTS

This longitudinal study included older adults aged ≥60 years without cognitive impairment who participated in National Institute for Longevity Sciences - Longitudinal Study of Aging.

MEASUREMENTS

Cognitive function was assessed using the MMSE. Body composition was measured by a dual-energy X-ray absorptiometry system. Then, BMI, fat mass index (FMI), fat-free mass index (FFMI), and muscle mass index (MMI) were calculated. The changes in body composition over 6 years (second wave to fifth wave) were calculated, and three groups were created: decreased group, decrease of >5%; stable group, change within 5%, and increased group, increase of >5%. In statistical analysis, a linear mixed model was applied by sex to investigate the influences of body composition changes on cognitive function over 4 years (fifth wave to seventh wave).

RESULTS

This study analyzed 515 participants (mean age, 67.05 years; 53.4% men). Men with decreased group in FFMI and MMI exhibited faster declines in MMSE scores than those with stable group (β [95% CI]: FFMI, -0.293 [-0.719 to -0.020]; MMI, -0.472 [-0.884 to -0.059]). In women, there was no significant association between body composition changes and cognitive functions.

CONCLUSIONS

Decrease in fat-free mass and muscle mass is associated with faster cognitive declines in men. These results suggest the importance of continuous monitoring of muscle mass to prevent cognitive decline in later life.

Remimazolam anaphylaxis confirmed by serum tryptase elevation and skin test

Anaphylactic reactions during the induction of general anaesthesia are rare. Anaesthetists should determine the pathogenesis of anaphylaxis in order to establish appropriate treatment and prevent recurrence. Very little clinical information has been published to date about anaphylaxis induced by the recently launched drug remimazolam. A 78-year-old man, scheduled for elective surgery for colon cancer, became profoundly hypotensive and hypoxic shortly following the induction of general anaesthesia with remimazolam, remifentanil and rocuronium. His physiological derangement was successfully managed with adrenaline, vasopressors and intravenous fluid resuscitation. His serum tryptase level was significantly elevated and an intradermal test with diluted remimazolam revealed a positive reaction, confirming the diagnosis of anaphylaxis. We believe this is the first case report of remimazolam-induced anaphylactic shock diagnosed with a serum tryptase elevation and positive skin test.

Association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan: a cohort study

Background

There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial.

Purpose

We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan.

Methods

From the data of 2780 patients with stable angina who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referred non-invasive imaging tests, 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1 year.

Results

Patients with ≥10% myocardial ischemia (n=173) were older than patients with <10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (9.1% vs. 1.2%, P<0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to <10% myocardial ischemia for MACEs remained significant (adjusted hazard ratio [95% confidence interval], 2.40 [1.09–5.26], P=0.029).

Conclusion

The presence of ≥10% myocardial ischemia was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.

Funding Acknowledgement

Type of funding sources: None. Study flowchartOutcomes

Subthreshold membrane potential dynamics of posterior parietal cortical neurons coupled with hippocampal ripples

During behavioral states of immobility, sleep, and anesthesia, the hippocampus generates high-frequency oscillations called ripples. Ripples occur simultaneously with synchronous neuronal activity in the neocortex, known as slow waves, and contribute to memory consolidation. During these ripples, various neocortical regions exhibit modulations in spike rates and local field activity irrespective of whether they receive direct synaptic inputs from the hippocampus. However, little is known about the subthreshold dynamics of the membrane potentials of neocortical neurons during ripples. We patch-clamped layer 2/3 pyramidal cells in the posterior parietal cortex (PPC), a neocortical region that is involved in allocentric spatial representation of behavioral exploration and sequential series of relevant action potentials during ripples. We simultaneously monitored the membrane potentials of post hoc-identified PPC neurons and the local field potentials of the hippocampus in anesthetized mice. More than 50% of the recorded PPC neurons exhibited significant depolarizations and/or hyperpolarizations during ripples. Histological inspections of the recorded neurons revealed that the ripple-modulated PPC neurons were distributed in the PPC in a spatially non-biased fashion. These results suggest that hippocampal ripples are widely but selectively associated with the subthreshold dynamics of the membrane potentials of PPC neurons even though there is no monosynaptic connectivity between the hippocampus and the PPC.

Correlation between alterations in blood flow of malignant lymphomas after induction chemotherapies and clinical outcomes: a pilot study utilising contrast-enhanced ultrasonography for early interim evaluation of lymphoma treatment

AIM

To clarify the utility of contrast-enhanced ultrasonography (CEUS) for interim evaluation of response to chemotherapy in lymphoma treatment.

MATERIALS AND METHODS

CEUS was performed both before (day 0) and after the treatment (7 and/or 14 days), and a time-intensity curve was obtained. The patients were divided into two groups (complete remission [CR] group and non-CR group) according to the results of conventional response evaluation, and peak enhancement (PE), time to peak enhancement, perfusion index (PI), the total area under the curve during wash-in (AUC-in), and the total AUC were compared between the groups.

RESULTS

Among 27 patients with various types of lymphoma, the median change ratio of PE and PI at day 7 evaluation were significantly different between the CR group and the non-CR group (0.81 versus 1.39, p=0.017 for PE and 0.92 versus 2.09, p=0.010 for PI). The change ratio of PE < 1.09 (specificity: 86%; sensitivity, 88%) and PI < 1.65 (specificity: 86%; sensitivity: 94%) distinguished CR from non-CR. Patients who achieved a PE change ratio <1.09 or a PI change ratio <1.65 had significantly better estimated progression-free survival (p<0.001).

CONCLUSION

The present study demonstrated that changes in tumour perfusion parameters evaluated with CEUS at 1 week after the treatment initiation were significantly different between lymphoma patients in CR group and non-CR group. Alterations in perfusion parameters evaluated via CEUS could impact the prognosis of lymphoma patients.

A genome-wide DNA methylation signature for SETD1B-related syndrome

SETD1B is a component of a histone methyltransferase complex that specifically methylates Lys-4 of histone H3 (H3K4) and is responsible for the epigenetic control of chromatin structure and gene expression. De novo microdeletions encompassing this gene as well as de novo missense mutations were previously linked to syndromic intellectual disability (ID). Here, we identify a specific hypermethylation signature associated with loss of function mutations in the SETD1B gene which may be used as an epigenetic marker supporting the diagnosis of syndromic SETD1B-related diseases. We demonstrate the clinical utility of this unique epi-signature by reclassifying previously identified SETD1B VUS (variant of uncertain significance) in two patients.

P4412Association of sleep duration with cardio-metabolic risk leading to development of atherosclerotic cardiovascular disease

Background

Sleep duration, mostly of short duration, has emerged as a potential factor in adverse cardio-metabolic risk. We investigated the relationship between sleep duration and cardio-metabolic risk leading to atherosclerotic cardiovascular disease (ASCVD).

Purpose

We examined the association between sleep duration and cardio-metabolic risk in Japanese men.

Methods

This cross-sectional study was conducted using a sample of 6,907 apparent healthy men who had undergone medical examinations at the Health Planning Center of Nihon University Hospital between April, 2015 and May, 2016. The relationship between waist circumference, homeostasis model assessment of insulin resistance (HOMA-IR), HbA1c, non-high-density lipoprotein cholesterol (non-HDL-C) level, and sleep duration was evaluated.

Results

Both unusually short and long sleep durations were associated with waist circumference, impaired glucose tolerance and high non-HDL-C level (Figure). Compared with men sleeping 7 to 8 hours, the relative risk of abdominal obesity (defined according to the Japanese criteria for metabolic syndrome as a waist circumference of 85cm≥) among men sleeping ≥8 h was 1.27 (95% Confidence interval (CI), 1.05–1.55, p<0.01); the relative risk of a high HOMA-IR (2.0≥) level among men sleeping <5 h was 1.43 (95% CI, 1.00–2.05, p<0.05); among men sleeping ≥8 h the relative risk was 1.38 (95% CI, 1.08–1.77, p=0.01); the relative risk of a HbA1c level of ≥5.6% (defined as “high” by a specialized life style checkup program for the detection of symptoms of metabolic syndrome in Japan) among men sleeping <5 h was 1.39 (95% CI, 1.01–1.65, p<0.05); the relative risk of a non-HDL-C level of ≥170 mg/dL (defined as “high” by the Japanese Arteriosclerosis Society based on a lipid control target value for the primary prevention of ASCVD) among men sleeping ≥8 was 1.40 (95% CI, 1.13–1.76, p<0.01). These analyses were adjusted for age, psychological stress, and the use of cholesterol-lowering, blood-pressure lowering, and anti-diabetic medications.

Conclusion

The results suggest that unusually short and long sleep durations may increase cardio-metabolic risk. To further reduce the risk of ASCVD, it may be of particular importance to emphasize adequate sleep duration.

Evaluation of the effect of a heat-killed lactic acid bacterium, Enterococcus faecalis 2001, on oral candidiasis

The effect of a preparation of heat-killed Gram-positive lactic acid bacteria Enterococcus faecalis 2001 (EF-2001) on oral candidiasis was evaluated by two studies. An in vitro study was performed to assess the inhibitory effect on mycelial growth of Candida strains isolated from a patient with oral candidiasis, and a clinical study was done in patients with oral candidiasis. In the in vitro study, EF-2001 inhibited mycelial growth of IT-1, a Candida strain isolated from a patient with oral candidiasis, at concentrations ≥2.34×109 cells/ml. An open clinical study was performed in 13 patients with oral candidiasis. The subjects took a powder containing 7.5×1011 heat-killed EF-2001 once a day before bedtime for seven consecutive days. In 11 of the 12 patients available for analysis (92%), the oral Candida load (cfu/swab) showed a significant decrease (P=0.01079, d=-0.437). There was a 55% decrease of Candida albicans and a 93.8% decrease of Candida glabrata. The following symptoms showed significant improvement: tinnitus (P=0.048, d=-0.462), cold feeling (P=0.048, d=-0.463), and depression (P=0.019, d=-0.34). In addition, 4 out of 26 oral symptoms tended to improve. These results suggest that EF-2001 significantly decreased the oral Candida load in patients with oral candidiasis by inhibiting mycelial growth and that EF-2001 is an effective treatment for oral candidiasis.

Novel WWOX deleterious variants cause early infantile epileptic encephalopathy, severe developmental delay and dysmorphism among Yemenite Jews

The human WW Domain Containing Oxidoreductase (WWOX) gene was originally described as a tumor suppressor gene. However, recent reports have demonstrated its cardinal role in the pathogenesis of central nervous systems disorders such as epileptic encephalopathy, intellectual disability, and spinocerebellar ataxia. We report on six patients from three unrelated families of full or partial Yemenite Jewish ancestry exhibiting early infantile epileptic encephalopathy and profound developmental delay. Importantly, four patients demonstrated facial dysmorphism. Exome sequencing revealed that four of the patients were homozygous for a novel WWOX c.517-2A > G splice-site variant and two were compound heterozygous for this variant and a novel c.689A > C, p.Gln230Pro missense variant. Complementary DNA sequencing demonstrated that the WWOX c.517-2A > G splice-site variant causes skipping of exon six. A carrier rate of 1:177 was found among Yemenite Jews. We provide the first detailed description of patients harboring a splice-site variant in the WWOX gene and propose that the clinical synopsis of WWOX related epileptic encephalopathy should be broadened to include facial dysmorphism. The increased frequency of the c.517-2A > G splice-site variant among Yemenite Jews coupled with the severity of the phenotype makes it a candidate for inclusion in expanded preconception screening programs.

Anthropometric Assessment After Proctocolectomy Due to Ulcerative Colitis

BACKGROUND

Postoperative changes in patient anthropometric and nutritional statuses after proctocolectomy due to ulcerative colitis (UC) are unclear.

PATIENTS AND METHODS

Between January 2015 and December 2017, nine patients who underwent proctocolectomy with temporary ileostomy (PTI) for UC at our hospital were enrolled in this study. For the comparison group, eight patients who underwent low anterior resection (LAR) with temporary ileostomy for rectal cancer in the same period were recruited. Data, including body weight; body mass index (BMI); levels of total protein, albumin, cholinesterase, and hemoglobin; and lymphocyte counts, were analyzed. The changes in these parameters before surgery until 6 months after surgery were compared.

RESULTS

Before surgery, the levels of total protein, albumin, cholinesterase, hemoglobin and lymphocyte counts in the PTI group were significantly worse than those in the LAR group. However, significant differences were not identified in these factors at 1 month after surgery. The BMI was significantly lower in the PTI group than in the LAR group until 3 months after surgery. An increase in body weight to greater than that prior to surgery was found from 4 months after surgery in the PTI group. The LAR group did not have any effect of surgery in terms of any factor.

CONCLUSION

BMI appears to be the most useful predictor of clinical and nutritional changes postoperatively.

Usefulness of Fecoflowgram for Assessment of Defecation after Intersphincteric Resection

AIM

We have developed an imaging functional assessment of defecation after partial intersphincteric resection (ISR) by fecoflowgram obtained by defecography.

PATIENTS AND METHODS

Between January 2012 and December 2014, 6 patients with temporary ileostomy who underwent partial ISR for lower rectal cancer at our hospital were enrolled in this study. Defecography was performed 2 weeks after closure of the ileostomy. The defecation of all patients was evaluated by defecography and a fecoflowgram calculated from defecography. During the same period, the control group was comprised of 2 male and 2 female healthy volunteers.

RESULTS

The descent of the perineum and linearization of the anorectal angle was observed relative to normal defecation in the healthy volunteers. All barium was discharged by a single abdominal pressure within 5 s in the controls. In patients after partial ISR, all barium could not be discharged by a single abdominal pressure. The time course of pressure distribution after ISR was lower than that of healthy volunteers, which could not be evaluated by defecography. Defecation time in patients following ISR was longer than that of healthy volunteers.

CONCLUSION

Fecoflowgrams calculated from defecography seem to be useful for functional assessment of defecation after rectal resection.

Usefulness of TAS-102 as Third-line Chemotherapy for Metastatic Colorectal Cancer

BACKGROUND/AIM

The feasibility and oncological outcomes of treatment with TAS-102, that is recommended as third-line chemotherapy for patients with metastatic colorectal cancer (mCRC), remain unknown.

PATIENTS AND METHODS

Between 2013 and 2015, seven patients (five males, two females) with mCRC who were administered TAS-102 as third-line chemotherapy at our Institution were retrospectively studied. During the same period, seven patients with mCRC with Kirsten rat sarcoma viral oncogene homolog (KRAS) wild-type primary lesions who were administered irinotecan with panitumumab comprised the control group.

RESULTS

The duration of third-line chemotherapy in the TAS-102 group was 217.0 (range=136-337) days compared to 226.9 (range=122-335) days in the control group, with no significant difference in the duration of administration between the two groups. No significant difference in overall survival was identified between the two groups No serious adverse effects were encountered in either group.

CONCLUSION

TAS-102 may be suitable as third-line chemotherapy for patients with mCRC.

Estimation of Arterial Mechanical Properties from Aortic and Tonometric Arterial Pressure Waveforms

Although arterial mechanical properties have been evaluated using arterial input impedance, the relative difficulty in accurate flow measurement made the value of impedance somewhat limited. To develop an alternative method to evaluate arterial mechanical properties, we analyzed the aortic pressure (AoP)-radial arterial pressure (RAP) relationship because of relative ease in obtaining peripheral pressure waveform by tonometry. In 8 patients we simultaneously recorded aortic root and radial arterial pressure waveforms. We calculated the transfer function from AoP to RAP. We then fitted the transfer function to a model of a lossless uniform elastic tube terminated with a modified Windkessel model. The fact that the model transfer function predicted AoP from RAP waveform with considerable accuracy indicated that the model represented the arterial mechanical properties well. We conclude that we can estimate the arterial mechanical properties by the pressure-pressure transfer function analysis.

Detection of copy number variations in epilepsy using exome data

Epilepsies are common neurological disorders and genetic factors contribute to their pathogenesis. Copy number variations (CNVs) are increasingly recognized as an important etiology of many human diseases including epilepsy. Whole-exome sequencing (WES) is becoming a standard tool for detecting pathogenic mutations and has recently been applied to detecting CNVs. Here, we analyzed 294 families with epilepsy using WES, and focused on 168 families with no causative single nucleotide variants in known epilepsy-associated genes to further validate CNVs using 2 different CNV detection tools using WES data. We confirmed 18 pathogenic CNVs, and 2 deletions and 2 duplications at chr15q11.2 of clinically unknown significance. Of note, we were able to identify small CNVs less than 10 kb in size, which might be difficult to detect by conventional microarray. We revealed 2 cases with pathogenic CNVs that one of the 2 CNV detection tools failed to find, suggesting that using different CNV tools is recommended to increase diagnostic yield. Considering a relatively high discovery rate of CNVs (18 out of 168 families, 10.7%) and successful detection of CNV with <10 kb in size, CNV detection by WES may be able to surrogate, or at least complement, conventional microarray analysis.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present possible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next decade, with the intention of providing information to the astronomy community to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals, and study the capability of the network to determine the sky location of the source. We report our findings for gravitational-wave transients, with particular focus on gravitational-wave signals from the inspiral of binary neutron star systems, which are the most promising targets for multi-messenger astronomy. The ability to localize the sources of the detected signals depends on the geographical distribution of the detectors and their relative sensitivity, and [Formula: see text] credible regions can be as large as thousands of square degrees when only two sensitive detectors are operational. Determining the sky position of a significant fraction of detected signals to areas of 5-[Formula: see text] requires at least three detectors of sensitivity within a factor of [Formula: see text] of each other and with a broad frequency bandwidth. When all detectors, including KAGRA and the third LIGO detector in India, reach design sensitivity, a significant fraction of gravitational-wave signals will be localized to a few square degrees by gravitational-wave observations alone.

Response to Lefebvre et al

Congenital scoliosis (CS) is a common vertebral malformation with incidence of up to 1 of 1000 births worldwide. Recently, TBX6 has been reported as the first disease gene for CS: about 10% of CS patients are compound heterozygotes of rare null mutations and a common haplotype composed by 3 SNPs in TBX6. Lefebvre et al in this journal reported that 2 patients with spondylocostal dysostosis (SCD), a rare skeletal dysplasia affecting spine and ribs also have TBX6 mutations: 1 carried the microdeletion and a rare missense variant, and another 2 rare missense variants. We investigated the pathogenicity of the 3 missense variants in SCD by a luciferase assay. The results were negative for the proposal of Lefebvre et al. We consider these 2 SCD patients are more probably compound heterozygotes of null mutations and a common risk haplotype just as CS patients with TBX6 mutations.

Identification of novel BCL11A variants in patients with epileptic encephalopathy: Expanding the phenotypic spectrum

BCL11A encodes a zinc finger protein that is highly expressed in hematopoietic tissues and the brain, and that is known to function as a transcriptional repressor of fetal hemoglobin (HbF). Recently, de novo variants in BCL11A have been reported in individuals with intellectual disability syndrome without epilepsy. In this study, we performed whole-exome sequencing of 302 patients with epileptic encephalopathies (EEs), and identified 2 novel BCL11A variants, c.577delC (p.His193Metfs*3) and c.2351A>C (p.Lys784Thr). Both the patients shared major physical features characteristic of BCL11A-related intellectual disability syndrome, suggesting that characteristic physical features and the persistence of HbF should lead clinicians to suspect EEs caused by BCL11A pathogenic variants. Patient 1, with a frameshift variant, presented with Lennox-Gastaut syndrome, which expands the phenotypic spectrum of BCL11A haploinsufficiency. Patient 2, with a p.Lys784Thr variant, presented with West syndrome followed by drug-resistant focal seizures and more severe developmental disability. These 2 newly described patients contribute to delineating the associated, yet uncertain phenotypic characteristics of BCL11A disease-causing variants.

A novel missense mutation affecting the same amino acid as the recurrent PACS1 mutation in Schuurs-Hoeijmakers syndrome

A novel causative variant (c.608G>A, p.Arg203Gln) in PACS1.

Novel biallelic SZT2 mutations in 3 cases of early-onset epileptic encephalopathy

The seizure threshold 2 (SZT2) gene encodes a large, highly conserved protein that is associated with epileptogenesis. In mice, Szt2 is abundantly expressed in the central nervous system. Recently, biallelic SZT2 mutations were found in 7 patients (from 5 families) presenting with epileptic encephalopathy with dysmorphic features and/or non-syndromic intellectual disabilities. In this study, we identified by whole-exome sequencing compound heterozygous SZT2 mutations in 3 patients with early-onset epileptic encephalopathies. Six novel SZT2 mutations were found, including 3 truncating, 1 splice site and 2 missense mutations. The splice-site mutation resulted in skipping of exon 20 and was associated with a premature stop codon. All individuals presented with seizures, severe developmental delay and intellectual disabilities with high variability. Brain MRIs revealed a characteristic thick and short corpus callosum or a persistent cavum septum pellucidum in each of the 2 cases. Interestingly, in the third case, born to consanguineous parents, had unexpected compound heterozygous missense mutations. She showed microcephaly despite the other case and previous ones presenting with macrocephaly, suggesting that SZT2 mutations might affect head size.

Pancreatoduodenectomy with portal vein resection for distal cholangiocarcinoma

BACKGROUND

Little is known about the value of portal vein (PV) resection in distal cholangiocarcinoma. The aim of this study was to evaluate the clinical significance of PV resection in distal cholangiocarcinoma.

METHODS

Patients who underwent pancreatoduodenectomy (PD) for distal cholangiocarcinoma between 2001 and 2010 at one of 31 hospitals in Japan were reviewed retrospectively with special attention to PV resection. Short- and long-term outcomes were evaluated.

RESULTS

In the study interval, 453 consecutive patients with distal cholangiocarcinoma underwent PD, of whom 31 (6·8 per cent) had combined PV resection. The duration of surgery (510 versus 427 min; P = 0·005) and incidence of blood transfusion (48 versus 30·7 per cent; P = 0·042) were greater in patients who had PV resection than in those who did not. Postoperative morbidity and mortality were no different in the two groups. Several indices of tumour progression, including high T classification, lymphatic invasion, perineural invasion, pancreatic invasion and lymph node metastasis, were more common in patients who had PV resection. Consequently, the incidence of R1/2 resection was higher in this group (32 versus 11·8 per cent; P = 0·004). Survival among the 31 patients with PV resection was worse than that for the 422 patients without PV resection (15 versus 42·4 per cent at 5 years; P < 0·001). Multivariable analyses revealed that age, blood loss, histological grade, perineural invasion, pancreatic invasion, lymph node metastasis and surgical margin were independent risk factors for overall survival. PV resection was not an independent risk factor.

CONCLUSION

PV invasion in distal cholangiocarcinoma is associated with locally advanced disease and several negative prognostic factors. Survival for patients who have PV resection is poor even after curative resection.