Significant correlates of nocturnal hypertension in patients with hypertension who are treated with antihypertensive drugs

OBJECTIVE

Nocturnal hypertension assessed by a home blood pressure monitoring (HBPM) device is associated with an increased risk of cardiovascular events. However, it is still difficult to assess nighttime blood pressure (BP) frequently. The purpose of this cross-sectional study was to identify significant correlates of nocturnal hypertension assessed by an HBPM device in patients with hypertension who are treated with antihypertensive drugs.

METHODS

We measured nighttime BP, morning BP, and evening BP by an HBPM device for 7 consecutive days in 365 medicated patients with hypertension.

RESULTS

Of the 365 subjects, 138 (37.8%) had nocturnal hypertension defined as a mean nighttime systolic BP of ≥120 mmHg. Receiver operating characteristic curve analyses showed that the diagnostic accuracy of morning systolic BP for subjects with nocturnal hypertension was significantly superior to that of evening systolic BP (P=0.04) and that of office systolic BP (P<0.001). Multivariate analysis revealed that morning systolic BP of 125-<135 mmHg (OR, 2.26; 95% CI, 1.13-4.58; P=0.02), morning systolic BP of ≥135 mmHg (OR, 16.4; 95% CI, 8.20-32.7; P<0.001), and a history of cerebrovascular disease (OR, 3.99; 95% CI, 1.75-9.13; P=0.001) were significantly associated with a higher risk of nocturnal hypertension and that bedtime dosing of antihypertensive drugs was significantly associated with a lower risk of nocturnal hypertension (OR, 0.56; 95% CI, 0.32-0.97; P=0.04).

CONCLUSIONS

Morning systolic BP of ≥125 mmHg, a history of cerebrovascular disease, and bedtime dosing were significant correlates of nocturnal hypertension in medicated patients with hypertension, and may help detect this risky BP condition.

Long-distance polarizing microscope system combined with solenoid-type magnet for microscopy and simultaneous measurement of physical parameters

We have developed a long-distance polarizing microscope system combined with a solenoid-type superconducting magnet. By inserting an infinity-corrected objective lens into the magnet, direct or polarizing microscope images are observed in magnetic fields of up to 12 T at various temperatures down to 2 K. Through magneto-optical measurements in the transmission geometry, the local magnetization process of a transparent magnet is evaluated in areas of 10 × 10 µm². This system enables simultaneous measurements of other physical properties over a wide range of temperatures and magnetic fields. The basic principle of the proposed long-distance microscopy can be applied to imaging experiments in various research fields, particularly biology and chemistry.

Multipole polaron in the devil's staircase of CeSb

Rare-earth intermetallic compounds exhibit rich phenomena induced by the interplay between localized f orbitals and conduction electrons. However, since the energy scale of the crystal-electric-field splitting is only a few millielectronvolts, the nature of the mobile electrons accompanied by collective crystal-electric-field excitations has not been unveiled. Here, we examine the low-energy electronic structures of CeSb through the anomalous magnetostructural transitions below the Néel temperature, ~17 K, termed the 'devil's staircase', using laser angle-resolved photoemission, Raman and neutron scattering spectroscopies. We report another type of electron-boson coupling between mobile electrons and quadrupole crystal-electric-field excitations of the 4f orbitals, which renormalizes the Sb 5p band prominently, yielding a kink at a very low energy (~7 meV). This coupling strength is strong and exhibits anomalous step-like enhancement during the devil's staircase transition, unveiling a new type of quasiparticle, named the 'multipole polaron', comprising a mobile electron dressed with a cloud of the quadrupole crystal-electric-field polarization.

Massive calcification around large joints in a patient subsequently diagnosed with adult-onset hypophosphatasia

We report a 64-year-old Japanese woman with a history of progressive loss of motor function and painful swelling of large joints. At the age of 54, profound calcification appeared around the shoulder and hip joints, which did not heal after repeated surgical resections. Iliac bone biopsy revealed osteomalacic changes. Laboratory data showed low serum alkaline phosphatase (ALP) activity and a high urine phosphoethanolamine (PEA) concentration with normal serum calcium, phosphate, and fibroblast growth factor 23 (FGF23) levels. Subsequent genetic analysis of the ALPL gene confirmed the diagnosis of hypophosphatasia (HPP) with the identification of a heterozygous single nucleotide deletion, c.1559delT (p.Leu520ArgfsX86). We started a mineral-targeted enzyme replacement therapy, asfotase alfa (AA), to treat the patient's musculoskeletal symptoms. A follow-up bone biopsy after 12 months of AA treatment showed improvement of osteomalacia. Calcified deposits around the large joints were unchanged radiographically. To our knowledge, this is the first report of a patient with an adult-onset HPP who presented with profound calcification around multiple joints. Nonspecific clinical signs and symptoms in patients with adult-onset HPP often result in delayed diagnosis or misdiagnosis. We propose that bone biopsy and genetic analysis should be considered along with laboratory analysis for all patients with ectopic calcification around joints of unknown etiology for accurate diagnosis and better treatment.

Devil's staircase transition of the electronic structures in CeSb

Solids with competing interactions often undergo complex phase transitions with a variety of long-periodic modulations. Among such transition, devil's staircase is the most complex phenomenon, and for it, CeSb is the most famous material, where a number of the distinct phases with long-periodic magnetostructures sequentially appear below the Néel temperature. An evolution of the low-energy electronic structure going through the devil's staircase is of special interest, which has, however, been elusive so far despite 40 years of intense research. Here, we use bulk-sensitive angle-resolved photoemission spectroscopy and reveal the devil's staircase transition of the electronic structures. The magnetic reconstruction dramatically alters the band dispersions at each transition. Moreover, we find that the well-defined band picture largely collapses around the Fermi energy under the long-periodic modulation of the transitional phase, while it recovers at the transition into the lowest-temperature ground state. Our data provide the first direct evidence for a significant reorganization of the electronic structures and spectral functions occurring during the devil's staircase.

Moderating effect of schizotypy on the relationship between smoking and neurocognition

Purpose

Smoking rates in schizotypic individuals are shown to be elevated, as in patients with schizophrenia, although findings on the association of smoking with different symptomatology of schizotypy have been mixed. Moreover, possible moderating effects of schizotypy on the relationship between smoking and cognition have not been well documented.

Subjects and methods

The Schizotypal Personality Questionnaire (SPQ) and the full version of the Wechsler Memory Scale-Revised (WMS-R) were administered to 501 healthy adults. Subjects were divided into smokers (n = 85) and non-smokers (n = 416) based on the presence/absence of current smoking.

Results

The analysis of covariance (ANCOVA) on the three factor scores as well as the total score of the SPQ, controlling for age and gender, revealed that cognitive-perceptual factor was significantly associated with an increased rate of smoking (P = 0.048). The ANCOVA on the WMS-R indices, with smoking group as a fixed factor and age, gender and total SPQ score as covariates, revealed that the schizotypy-by-smoking interaction was significant for attention/working memory (P = 0.029).

Discussion and conclusion

Positive schizotypy may be associated with more smoking. Schizotypy and smoking could interact with each other to negatively affect attention/working memory.

P974Efficacy of plaque debulking for bifurcated or ostial lesion by directional coronary atherectomy before 2nd generation drug eluting stent (PERFECT2)

Objectives

We sought to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before 2nd generation drug-eluting stent (DES) implantation for bifurcated coronary lesions.

Background

Percutaneous coronary intervention (PCI) for bifurcated lesions still remains complex and challenging in terms of restenosis or stent thrombosis regardless of whether simple or complex stenting used.

Methods

Patients with bifurcated lesions were enrolled in this prospective multicenter registry. Pre-2nd generation DES plaque debulking with a novel DCA was conducted. All patients were scheduled to perform a follow up (9–12 months) angiography (coronary angiography or coronary computed tomography). The primary end point was the target vessel failure (TVF) at follow-up. Secondary end points were procedure-related events and major adverse cardiac events at 1 year.

Results

A total of 77 patients with bifurcated lesions were enrolled. PCI with DCA was performed successfully in all without any major procedure-related event and only 1 case needed complex stenting. TVF rate at 9–12 months follow up was 3.9% (3 of 77) and those were all associated with revascularization of the target vessel. Restenosis was only observed at ostial of main-branch in 3cases. No death, no coronary artery bypass grafting, and no myocardial infarction were reported in the patients within the first year.

Figure1

Conclusion

DCA before 2nd generation DES implantation can possibly avoid complex stenting and provide a good mid-term outcome in patients with bifurcated lesions.

Acknowledgement/Funding

None

124Impact of intimal tracking for recanalization of CTO lesions on long-term clinical outcomes

Background

For recanalization of coronary chronic total occlusion (CTO) lesions, subintimal guidewire tracking in both antegrade and retrograde approaches are commonly used.

Purpose

This study aimed to assess the impact of subintimal tracking on long-term clinical outcomes after recanalization of CTO lesions.

Methods

Between January 2009 and December 2016, 474 CTO lesions (434patients) were successfully recanalized in our center. After guidewire crossing in a CTO lesion, those lesions were divided into intimal tracking group (84.6%, n=401) and subintimal tracking group (15.4%, n=73) according to intravascular ultrasound (IVUS) findings. Long-term clinical outcomes including death, target lesion revascularization (TLR), target vessel revascularization (TVR) were compared between the two groups. In addition, the rate of re-occlusion after successful revascularization was also evaluated.

Results

The median follow-up period was 4.7 years (interquartile range, 2.8–6.1). There was no significant difference of the rate of cardiac death between the two groups (intimal tracking vs. subintimal tracking: 7.0% vs. 4.1%; hazard ratio, 0.61; 95% confidence interval [CI], 0.19 to 2.00; p=0.41), TLR (14.3% vs. 16.2%; hazard ratio, 1.34; 95% CI, 0.71 to 2.53; p=0.37), and TVR (17.5% vs. 20.3%; hazard ratio, 1.27; 95% CI, 0.72 to 2.23; p=0.42). However, the rate of re-occlusion was significantly higher in the subintimal tracking group than intimal tracking group at 3-years re-occlusion (4.2% vs. 14.5%; log-rank test, p=0.002, Figure). In the multivariate COX regression, subintimal guidewire tracking was an independent predictor of re-occlusion after CTO recanalization (HR: 5.40; 95% CI: 2.11–13.80; p<0.001).

Figure 1

Conclusions

Subintimal guidewire tracking for recanalization of coronary CTO was associated with significantly higher incidence of target lesion re-occlusion during long-term follow-up period.

Effects of the Dipeptidyl Peptidase 4 Inhibitor Alogliptin on Blood Pressure in Hypertensive Patients with Type 2 Diabetes Mellitus

BACKGROUND

The effects of dipeptidyl peptidase 4 (DPP-4) inhibitors on blood pressure in patients with diabetes mellitus (DM) are controversial. There is no information on the effect of DPP-4 inhibitors on blood pressure and arterial stiffness in hypertensive patients with DM. We evaluated the effects of alogliptin on blood pressure and arterial stiffness in hypertensive patients with type 2 diabetes mellitus (T2DM).

METHODS

Blood pressure and brachial-ankle pulse wave velocity (baPWV) were measured before and after 3, 6, and 12 months of treatment with alogliptin in 22 hypertensive patients with T2DM.

RESULTS

After 3, 6, and 12 months, alogliptin treatment decreased hemoglobin A1c from 7.0 ± 0.97% to 6.4 ± 0.61%, 6.3 ± 0.58%, and 6.3 ± 0.75% (P < 0.01, respectively), glucose from 8.6 ± 4.39 mmol/l to 7.05 ± 2.16, 7.05 ± 2.28, and 6.44 ± 1.50 mmol/l (P < 0.01, respectively), systolic blood pressure from 137 ± 18 mm Hg to 127 ± 13, 125 ± 15, and 120 ± 17 mm Hg (P < 0.01, respectively), diastolic blood pressure from 79 ± 13 mm Hg to 74 ± 8, 74 ± 10, and 70 ± 8 mm Hg (P < 0.01, respectively) and baPWV from 1,947 ± 349 cm/second to 1,774 ± 259, 1,856 ± 361, and 1,756 ± 286 cm/second (P < 0.01, respectively). A baseline baPWV value of 1,643 cm/second was the optimal cut-off value for patients who had reduced blood pressure after treatment with alogliptin (sensitivity of 83.3% and specificity of 75.0%).

CONCLUSIONS

Alogliptin was associated with improvements not only in glucose metabolism but also in blood pressure and arterial stiffness in hypertensive patients with T2DM. The cut-off value of baPWV may enable identification of responders of decrease in blood pressure by alogliptin in hypertensive patients with T2DM.

CLINICAL TRIALS REGISTRATION

Registration Number for Clinical Trial: UMIN000007722.

Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Mild Diabetes Mellitus Following Treatment With Pioglitazone: Reports of a Randomised Trial From The Japan Working Group for the Assessment Whether ioglitazone rotects DM Patients gainst e-Infarction (PPAR Study)

BACKGROUND

Secondary prevention in patients with myocardial infarction (MI) is critically important to prevent ischaemic heart failure and reduce social burden. Pioglitazone improves vascular dysfunction and prevents coronary atherosclerosis, mainly via anti-inflammatory and antiatherogenic effects by enhancing adiponectin production in addition to antihyperglycemic effects, thus suggesting that pioglitazone attenuates cardiovascular events in patients with mild (HbA1c levels < 6·5%) diabetes mellitus (DM). Therefore, we evaluated the effects of pioglitazone on cardiovascular events in patients with both previous MI and mild DM.

METHODS

In this multicentre, prospective, randomised, open, blinded-endpoint trial, we randomly assigned 630 patients with mild DM with a history of MI to undergo either DM therapy with (pioglitazone group) or without (control group) pioglitazone. DM was diagnosed using the 75-g oral glucose tolerance test, and mild DM was defined if HbA1c level was < 6·5%. The primary endpoint was the composite of cardiovascular death and hospitalisation caused by acute MI, unstable angina, coronary revascularisation (including percutaneous coronary intervention and cardiac bypass surgery), and stroke.

FINDINGS

HbA1C levels were 5·9 and 5·8% (p = 0·71) at baseline and 6·0 and 5·8% (p < 0·01) at 2 years for the control and pioglitazone groups, respectively.The primary endpoint was observed in 14·2% and 14·1% patients in the control and pioglitazone groups during two years (95% confidential interval (CI):0.662-1·526, p = 0·98), respectively; the incidence of MI and cerebral infarction was 0·3% and 2·2% (95%CI: 0·786-32·415, p = 0·09) and 1·0% and 0·3% (95%CI: 0·051-3·662, p = 0·44), respectively. Post-hoc analyses of the 7-year observation period showed that these trends were comparable (21·9% and 19·2% in the control and pioglitazone groups, 95%CI: 0.618-1·237, p = 0·45).

INTERPRETATION

Pioglitazone could not reduce the occurrence of cardiovascular events in patients with mild DM and previous MI.

Rikkunshito simultaneously improves dyspepsia correlated with anxiety in patients with functional dyspepsia: A randomized clinical trial (the DREAM study)

BACKGROUND

Functional dyspepsia (FD), a heterogeneous disorder, involves multiple pathogenetic mechanisms. Developing treatments for FD has been challenging. We performed a randomized, placebo-controlled, double-blind clinical trial to determine the efficacy of rikkunshito, a Japanese herbal medicine, in FD patients.

METHODS

FD patients (n = 192) who met the Rome III criteria without Helicobacter pylori infection, predominant heartburn, and depression were enrolled at 56 hospitals in Japan. After 2 weeks of single-blind placebo treatment, 128 patients with continuous symptoms were randomly assigned to 8 weeks of rikkunshito (n = 64) or placebo (n = 61). The primary efficacy endpoint was global assessment of overall treatment efficacy (OTE). The secondary efficacy endpoints were improvements in upper gastrointestinal symptoms evaluated by the Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM), the Global Overall Symptom scale (GOS), and the modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (m-FSSG), and psychological symptoms evaluated by the Hospital Anxiety and Depression Scale (HADS).

KEY RESULTS

Rikkunshito increased OTE compared to placebo at 8 weeks (P = .019). Rikkunshito improved upper gastrointestinal symptoms (PAGI-SYM, GOS, and m-FSSG) at 8 weeks, especially postprandial fullness/early satiety (P = .015 and P = .001) and bloating (P = .007 and P = .002) of the PAGI-SYM subscales at 4 weeks and 8 weeks. Improvement of HADS at 8 weeks (P = .027) correlated with those of PAGI-SYM (r = .302, P = .001), GOS (r = .186, P = .044), and m-FSSG (r = .462, P < .001), postprandial fullness/early satiety (r = .226, P = .014), dyspepsia (r = .215, P = .019), and PDS (r = .221, P = .016).

CONCLUSION & INFERENCES

Rikkunshito may be beneficial for FD patients to simultaneously treat gastrointestinal and psychological symptoms.

Skull Bone Regeneration Using Chitosan⁻Siloxane Porous Hybrids-Long-Term Implantation

Burr holes in craniotomy are not self-repairing bone defects. To regenerate new bone at the sites of these defects, a good scaffold is required. Biodegradable hybrids including silica or siloxane networks have been investigated as bone tissue scaffolds. This study examined skull bone regeneration using chitosan-siloxane hybrids after long-term implantation (two and three years). After implantation of the hybrids, the surrounding cells migrated and formed fibrous tissues and blood vessels. Then, bone formation occurred from the surrounding blood vessels. Addition of calcium ions and coating with hydroxyapatite improved bone regeneration. Finally, the regenerated tissue area became smaller than the initial hole, and some areas changed to completed bone tissues.

Promoting Atoms into Delocalized Long-Living Magnetically Modified State Using Atomic Force Microscopy

We report on a low-temperature atomic force microscropy manipulation of Co atoms in ultrahigh vacuum on an oxidized copper surface in which the manipulated atom is kept delocalized above several surface unit cells over macroscopic times. The manipulation employed, in addition to the ubiquitous short-range tip-generated chemical forces, also long-range forces generated via Friedel oscillations of the metal charge density due to Co nanostructures prearranged on the surface by lateral manipulation. We show that our manipulation protocol requires mechanical control of the spin state of the Co atom.

A method for deciding the optimal anticoagulant infusion dose for blood purification therapy

BACKGROUND

The incidence of iatrogenic pseudoaneurysms has recently increased due to the more frequent use of high doses of anticoagulants in apheresis therapy. The reason why the decision for an appropriate dose of the anticoagulant is difficult is that such information about the material properties of adsorbers is not provided.

OBJECTIVE

To investigate the calculations to determine the optimal dose of heparin sodium to administer during apheresis.

METHODS

The calculations were based on experimental data obtained during an in vivo test using dogs and theoretical pharmacokinetics data obtained using a one compartment model.

RESULTS

When information regarding the adsorption isotherm of the adsorbent material that takes competitive adsorption into consideration was provided, the required anticoagulant dose for apheresis could be determined.

CONCLUSIONS

It is important to decide the optimal dose of anticoagulant that Information about the material's characteristics including data about its adsorption isotherm that takes competitive adsorption into consideration are provided before therapy. Then, if so, the calculation for required dose must be possible.

Percutaneous Transluminal Angioplasty for Intracranial Arteriosclerotic Lesions

Recent developments of the interventional neuroradiological technique made percutaneous transluminal angioplasty (PTA) possible even for intracranial arteries1.

We report our experiences of 17 cases treated by PTA including 9 intracranial internal carotid (ICA), 4 middle cerebral (MCA) and 4 vertebro-basilar arterial (VBA) stenoses and discuss the problems of the procedure.

All patients had cerebral ischemic symptoms and stenoses more than 60% calculated angiographically. Three of them were treated by PTA for residual stenoses after thrombolytic therapy for acute occlusion. We used PTA balloon catheters 2.0 mm to 3.5 mm in diameter (Stealth, Target therapeutics) for all PTA procedures. A PTA balloon was inflated for 1 min at 6 atm as a rule. All were successfully dilated (stenosis less than 50%) except one treated by PTA for residual MCA stenosis after thrombolytic therapy.

The patient died from massive infarction due to MCA re-occlusion caused by MCA dissection. Restenosis appeared in 4 of 16 patients. Repeated PTA was successfuly carried out for the 4 patients.

However, restenosis appeared in one of them but the patient is now on follow-up because of asymptomatic course.

PTA for intracranial arteries is an effective treatment but its indication should be determined strictly because of potential risk such as acute occlusion derived from dissection.

The Strategy of Dural Arteriovenous Fistula with Isolated Sinus

We treated 7 cases of dural arteriovenous fistulas (dAVF) with isolated sinus by transvenous direct embolization.

The fistulas located in the transverse-sigmoid sinus in 5 cases, superior sagittal sinus in 1 case and transverse-sigmoid and superior sagittal sinus in 1 case.

The initial symptoms were generalized convulsion in 2 cases, disturbed consciousness in 1 case, tinnitus in 2 cases and transient ischemic attack in 2 cases. We performed sinus packing with coils in all cases following transarterial embolization.

All patients improved neurologically after the treatments and AVFs completely disappeared in all cases.

Meticillin-resistant Staphylococcus aureus colonisation and infection in Thoroughbred racehorses and veterinarians in Japan

Meticillin-resistant Staphylococcus aureus (MRSA) infections have been confirmed in hospitalised Thoroughbred racehorses at the hospitals of two training centres in Japan since 2009. To investigate the source of infection, the authors examined the rate of nasal MRSA colonisation in 600 healthy Thoroughbred racehorses, 53 veterinarians and 16 office staff at the racehorse hospitals of the two training centres. MRSA was not isolated from healthy Thoroughbred racehorses or hospital office staff. However, MRSA was isolated from 16 veterinarians (30.1 per cent), and the colonisation rate was significantly higher in veterinarians than in the office staff of the same hospitals. Also, 10 of the 16 MRSA strains (62.5 per cent) isolated from veterinarians were classified as type II by staphylococcal cassette chromosome mec (SCCmec) typing and ST5 by multilocus sequence typing. Pulsed-field gel electrophoresis analysis demonstrated that these 10 MRSA strains of SCCmec type II and ST5 were genetically identical or very similar to 9 MRSA strains isolated from infected horses hospitalised at these hospitals between 2009 and 2013. These results indicate that SCCmec type II and ST5 MRSA strains were probably transmitted between veterinarians and infected horses.

Novel electronic ferroelectricity in an organic charge-order insulator investigated with terahertz-pump optical-probe spectroscopy

In electronic-type ferroelectrics, where dipole moments produced by the variations of electron configurations are aligned, the polarization is expected to be rapidly controlled by electric fields. Such a feature can be used for high-speed electric-switching and memory devices. Electronic-type ferroelectrics include charge degrees of freedom, so that they are sometimes conductive, complicating dielectric measurements. This makes difficult the exploration of electronic-type ferroelectrics and the understanding of their ferroelectric nature. Here, we show unambiguous evidence for electronic ferroelectricity in the charge-order (CO) phase of a prototypical ET-based molecular compound, α-(ET)₂I₃ (ET:bis(ethylenedithio)tetrathiafulvalene), using a terahertz pulse as an external electric field. Terahertz-pump second-harmonic-generation(SHG)-probe and optical-reflectivity-probe spectroscopy reveal that the ferroelectric polarization originates from intermolecular charge transfers and is inclined 27° from the horizontal CO stripe. These features are qualitatively reproduced by the density-functional-theory calculation. After sub-picosecond polarization modulation by terahertz fields, prominent oscillations appear in the reflectivity but not in the SHG-probe results, suggesting that the CO is coupled with molecular displacements, while the ferroelectricity is electronic in nature. The results presented here demonstrate that terahertz-pump optical-probe spectroscopy is a powerful tool not only for rapidly controlling polarizations, but also for clarifying the mechanisms of ferroelectricity.

Health-related quality of life in patients with lower rectal cancer after sphincter-saving surgery: a prospective 6-month follow-up study

This longitudinal descriptive study examined whether rectal cancer patients report changes in health-related quality of life (HRQOL) over a 6-month period after different types of sphincter-saving surgery (SSS): intersphincteric resection (ISR), ultra-low anterior resection (ULAR) and low anterior resection (LAR). It also compares HRQOL among the three groups of patients. Seventy-three patients from two hospitals in Japan completed questionnaires on HRQOL and defecation symptoms immediately before surgery and 1 and 6 months afterwards. Results showed that ISR patients had significantly worse HRQOL scores than ULAR and LAR patients and more defecation symptoms that persisted during the 6 months post-SSS. Thus, patients undergoing ISR require psychological and social support, including skills in competent self-management, during the early post-operative period. Furthermore, defecation problems substantially influence HRQOL. The first month post-SSS is particularly challenging. The assumption that HRQOL is better after SSS compared to living with a permanent stoma might not be valid.

Identification of beta-aspartylglycine in uremic serum and its toxicity

An unidentified ninhydrin-positive substance of acidic nature was found in the serum of uremic patients. This substance was isolated from hemodialysate by the methods of ion-exchange chromatography, gel-filtration and paper electrophoresis, and identified as beta-aspartylglycine by amino acid analysis, N-terminal amino acid determination and comparison with authentic sample synthesized in this laboratory. The quantitative determination of beta-aspartylglycine in serum revealed that the serum concentrations of beta-aspartyl-glycine in uremic patients increased much higher than those in normal subjects. The toxicity of beta-aspartylglycine in mice with acute renal failure induced by uranyl acetate was investigated. The mice given more than 1,0 g/kg body weight of beta-aspartylglycine showed behavioral alterations: low response to the stimuli and low activity, and some mice died by the injection of 4.0 g/kg body weight of the peptide. These results suggested that beta-aspartyl-glycine might be a possible factor which influences the development of uremic toxaemia.

Classification of chronic glomerulonephritis based on prognostic considerations

Based on the correlation of LM, EM and IF findings of kidney biopsy tissues with the clinical and laboratory findings as well as renal function, classification of primary GN is proposed with special reference to the smouldering and progressive forms of chronic GN. The two forms of chronic GN should be differentiated because their prognoses are different.

Clinical and Pathologic Study of Feline Merkel Cell Carcinoma With Immunohistochemical Characterization of Normal and Neoplastic Merkel Cells

The authors herein describe the morphologic and immunohistochemical features of normal Merkel cells as well as the clinicopathologic findings of Merkel cell carcinoma in cats. Merkel cells were characterized as vacuolated clear cells and were individually located in the epidermal basal layer of all regions examined. Clusters of Merkel cells were often observed adjacent to the sinus hair of the face and carpus. Immunohistochemically, Merkel cells were positive for cytokeratin (CK) 20, CK18, p63, neuron-specific enolase, synaptophysin, and protein gene product 9.5. Merkel cell carcinoma was detected as a solitary cutaneous mass in 3 aged cats (13 to 16 years old). On cytology, large lymphocyte-like cells were observed in all cases. Histologic examinations of surgically resected tumors revealed nests of round cells separated by various amounts of a fibrous stroma. Tumor cells were commonly immunopositive for CK20, CK18, p63, neuron-specific enolase, and synaptophysin, representing the characteristics of normal Merkel cells.

Randomised clinical trial: prevention of recurrence of peptic ulcers by rabeprazole in patients taking low-dose aspirin

BACKGROUND

Few studies have evaluated the effects of rabeprazole on low-dose aspirin (LDA)-induced gastroduodenal injuries.

AIM

To conduct a randomised, double-blind, triple-dummy, active-controlled, multicentre trial, named the PLANETARIUM study, to assess the efficacy, dose-response relationship and safety of rabeprazole for peptic ulcer recurrence in Japanese patients on long-term LDA therapy.

METHODS

Eligible patients had a history of endoscopically confirmed peptic ulcers and were receiving long-term LDA (81 or 100 mg/day) therapy for cardiovascular or cerebrovascular protection. Subjects were randomly segregated into three groups receiving rabeprazole 10 mg once daily (standard dose in Japan), rabeprazole 5 mg once daily, or teprenone (geranylgeranylacetone; mucosal protective agent commercially available in Japan) 50 mg three times per day as an active control. The primary endpoint was recurrence of peptic ulcers over 24 weeks.

RESULTS

Among 472 randomised subjects, 452 subjects (n = 151, 150, 151, respectively) constituted the full analysis set. The cumulative recurrence rates of peptic ulcers over 24 weeks in the 10- and 5-mg rabeprazole groups were 1.4% and 2.8%, respectively, both of which were significantly lower than that in the teprenone group (21.7%). The cumulative occurrence rate of bleeding ulcers over 24 weeks in the teprenone group was 4.6%, while bleeding ulcers were not observed in the 10- or 5-mg rabeprazole groups. Rabeprazole was well tolerated at both doses.

CONCLUSION

Rabeprazole prevents the recurrence of peptic ulcers with no evidence of a major dose-response effect in subjects on low-dose aspirin therapy.

Perioperative intensive insulin therapy using an artificial endocrine pancreas with closed-loop glycemic control system: the effects of no hypoglycemia

BACKGROUND

We examined whether perioperative intensive insulin therapy (IIT) using an artificial pancreas (AP) with a closed-loop glycemic control system can be used to prevent hypoglycemia in surgical patients.

METHODS

Between 2006 and 2012, perioperative glycemic control using an AP was performed in 427 patients undergoing general surgery. A total of 305 patients undergoing IIT using an AP in the target blood glucose range of 80 to 110 mg/dL were enrolled in the study. Data were collected prospectively and were reviewed or analyzed retrospectively.

RESULTS

No patients had hypoglycemia. Perioperative mean blood glucose level and achievement rates in target blood glucose range of 80 to 110 mg/dL were 100.5 ± 11.9 mg/dL and 88.1% ± 16.0%, respectively. For the 3 primary operative methods, including hepatic, pancreatic, and esophageal resections, there were no significant differences in glycemic control stability between the types of surgery.

CONCLUSION

Perioperative IIT using an AP with a closed-loop glycemic control system can be used to prevent hypoglycemia and maintain stable glycemic control with less variability of blood glucose concentration.

Postoperative Clostridium difficile infection with PCR ribotype 078 strain identified at necropsy in five Thoroughbred racehorses

Clostridium difficile is an important cause of acute enterocolitis in horses. We describe five cases of C difficile infection occurring postoperatively in Thoroughbred racehorses. Following diarrhoea or colic accompanied by a marked increase in packed cell volume (to ≥60 per cent) and leucopenia (≤4000 cells/μl) within two to four days after surgery in all five horses, four of them died or were euthanased because of colitis or severe diarrhoea. In these four horses, necrotising entero-typhlo-colitis was revealed by postmortem examination, and C difficile was recovered from the contents of the small and/or large intestine. The remaining horse was euthanased because of marked decline in general condition and the presence of a lung abscess, from which C difficile was isolated. The horse had had severe postoperative diarrhoea before the onset of respiratory disorder; laboratory tests for C difficile were not performed on the faeces. All C difficile isolates were toxin-A-positive, toxin-B-positive and actin-specific ADP-ribosyltransferase (CDT)-positive. The isolates were indistinguishable by pulsed field gel electrophoresis analysis, PCR ribotyping, and slpA sequence typing, and the slpA sequences and PCR ribotype patterns were identical to those of known PCR type 078. This case sequence might have been healthcare-associated infection, although there was about a four-month interval between each disease onset.

Randomised clinical trial: rabeprazole improves symptoms in patients with functional dyspepsia in Japan

BACKGROUND

The efficacy of proton pump inhibitors (PPIs) for treating functional dyspepsia (FD) is not well established.

AIM

This study, named the SAMURAI study, aimed to assess the efficacy and dose-response relationship of rabeprazole in Japanese patients with FD in a multicentre, double-blinded, randomised, placebo-controlled trial.

METHODS

Investigated FD was diagnosed using the Rome III criteria. Subjects who did not respond to 1 week of single-blind placebo treatment in a run-in period were randomly assigned to 8 weeks of double-blind treatment with rabeprazole 10 mg, 20 mg, 40 mg or placebo, once daily. Dyspeptic symptoms were assessed by a dyspepsia symptom questionnaire (7-point Likert scale) and symptom diary.

RESULTS

Of 392 subjects entered into the run-in period, 338 were randomly assigned. Although there was no significant difference between placebo and rabeprazole groups in complete symptom relief for four major dyspeptic symptoms, the satisfactory symptom relief of rabeprazole 20 mg was significantly higher than placebo according to the dyspepsia symptom questionnaire (45.3% vs. 28.2%, P = 0.027) and the symptom diary assessment (48.7% vs. 30.0%, P = 0.016). The efficacy was not influenced by syndrome type or Helicobacter pylori status. No statistically significant differences in the incidence of adverse events were seen among treatment groups.

CONCLUSIONS

Rabeprazole 20 mg once daily but not 10 or 40 mg significantly provides satisfactory symptom relief for functional dyspepsia (ClinicalTrials.gov, Number NCT01089543).

Perioperative glycemic control using an artificial endocrine pancreas in patients undergoing total pancreatectomy: tight glycemic control may be justified in order to avoid brittle diabetes

I dedicate this paper to the late Prof. Yukihiko Nosé with all my heart. In 2001, under the direction of Prof. Nosé and Prof. Brunicardi at Baylor College of Medicine, we published a review article entitled "Artificial endocrine pancreas" in JACS. Subsequently, we reported that perioperative tight glycemic control (TGC) using an artificial pancreas (AP) with a closed-loop system could stably maintain near-normoglycemia in total-pancreatectomized dogs. Based on this experimental study in Houston, since 2006, we have introduced perioperative TGC using an AP into clinical use in Kochi. As of 2011, this novel TGC method has provided safe and stable blood glucose levels in more than 400 surgical patients. In this paper, we report new clinical findings regarding perioperative TGC using an AP in total-pancreatectomized patients. TGC using an AP enables us to achieve stable glycemic control not only without hypoglycemia and hyperglycemia but also with less variation in blood glucose concentration from the target blood glucose range, even in patients with the most serious form of diabetes, so-called "brittle diabetes", undergoing total pancreatectomy. To the best of our knowledge, this is the first clinical report of TGC using an AP in patients undergoing total pancreatic resection.

Rapid induction of brain hypothermia by endovascular intra-arterial perfusion

OBJECTIVES

Achieving rapid, brain cooling has potentially important clinical implications. To investigate potential practicalities, we induced brain hypothermia in canines by perfusing cooled crystalloid solution into the carotid artery using an extracorporeal cooling-filtration system.

METHODS

Ringer's solution cooled to approximately 6.5 degrees C was infused at a rate of 3 ml/kg/min for 30 minutes into the right common carotid artery through an angiographic catheter via the right femoral artery in six adult canines (13.81 +/- 0.60 kg). Excessive fluid was ultrafiltrated through a venovenous extracorporeal circuit via the right femoral vein. Temperature was monitored in the cerebral hemispheres, the rectum and the vena cava. The extracellular lactate concentrations were measured by microdialysis in the frontal lobes.

RESULTS

Right brain temperature decreased to 33.6 +/- 2.0 degrees C from 37.7 +/- 1.1 degrees C 30 minutes after initiation of perfusion, while left brain and rectal temperatures were 34.3 +/- 1.7 and 34.1 +/- 1.3 degrees C, respectively. The cooling rate of the right cerebral hemisphere was 4.2 +/- 1.1 degrees C/ 30 minutes and advanced compared with the rectum (p<0.01), the left cerebral hemisphere and the vena cava (both p<0.05). There was no significant increase in the extracellular lactate concentrations in the cerebral hemispheres. Hemoglobin, hematocrit and cardiac function significantly changed during perfusion (p<0.05).

CONCLUSIONS

Brain hypothermia was rapidly and safely induced using an intra-arterial crystalloid infusion and an extracorporeal cooing-filtration system. With refinement and further assessment of metabolic and physiologic parameters, the method holds a potential for clinical utility.

Mandibular reconstruction using a poly(L-lactide) mesh combined with autogenous particulate cancellous bone and marrow: a prospective clinical study

The purpose of this study was to evaluate the stability and viability of mandibular bone regeneration using a poly(L-lactide) (PLLA) mesh and autogenous particulate cancellous bone and marrow (PCBM). Sixty-two procedures were undertaken at eight hospitals (22 malignant tumours, 30 benign tumours, five cysts, two osteomyelitis, two trauma, and one atrophy of the alveolar ridge); the success rate was 84%. The follow-up period was between 9 and 200 months (mean 88.2 months). Consequently, bone regeneration at 6 months postoperation was excellent in 35 cases (57%), good in 17 cases (27%), and poor in 10 cases (16%). In six of the 'poor' cases, the PLLA mesh was removed due to local infection early after surgery. Bone resorption>20% was observed in only one of 46 cases with a follow-up term of >1 year. There were no signs of any other adverse effects except in one case where a section of the tray broke off late in the follow-up period. It is concluded that this method is stable and effective due to favourable morphological and functional recovery and low invasiveness. It may thus be a useful alternative procedure for mandibular reconstruction.

Resolution of clinical symptoms after reopening of an occluded inferior petrosal sinus in a patient with a cavernous sinus dural arteriovenous fistula. A case report

We describe a rare case with a cavernous sinus (CS) dural arteriovenous fistula (DAVF) in which the clinical symptoms disappeared after the patient underwent reopening of an occluded inferior petrosal sinus (IPS). A 66-year-old woman presented with increased intraocular pressure, chemosis, and proptosis on the left side. Angiography demonstrated a left CS DAVF supplied by the dural branches of bilateral internal carotid arteries. The shunt flow was directed to the superior and inferior ophthalmic veins, while the bilateral IPSs were not opacified. Accordingly, a transvenous embolization of the fistula was attempted. Although the microcatheter was navigated to the cavernous sinus through the occluded left IPS, obliteration of the fistula was unsuccessful because of the failure of superselective catheterization at the fistulous point. However, the final image demonstrated the development of an antegrade shunt flow through the left IPS to the internal jugular vein and disappearance of the retrograde reflux to the superior and inferior ophthalmic veins. The patient's clinical symptoms immediately resolved after the operation, and the symptoms have not recurred during a one-year follow-up period. Inappropriate transvenous embolization of CS DAVFs can result in vascular complications arising from the unintentional redistribution of shunt flow. The present case illustrates that the disappearance of retrograde shunt flow to the ophthalmic veins after reopening of the occluded IPS may be sufficient if a superselective approach fails or is anticipated to result only in an incomplete embolization of the fistulous point.