The Effect of Motor Imagery Practice on an Aiming Task with Attentional Focus Cues

When one directs their attention to an intended effect (external focus of attention, EFOA), motor performance is generally better than when one directs their attention to their own body movements (internal focus of attention, IFOA). However, the effect of attentional focus is unclear when a skill is practiced through motor imagery (MI) in the absence of physical trials. Participants (N = 30, M = 22.33 yrs, SD = 2.69) in the present study completed three physical trials of a reciprocal aiming task before and (24-h) after MI practice. During MI practice, the EFOA (n = 15) and IFOA (n = 15) groups mentally practiced the task with no physical practice with EFOA-MI or IFOA-MI, respectively, for three consecutive days. Our results showed that both groups significantly improved in accuracy (F1,28 = 6.49, p = .017), supporting the benefit of MI in motor skill acquisition. However, a significant effect of attentional focus was not observed (F1.,28 = 0.445, p = 0.51). We discussed two potential explanations: EFOA/IFOA requires physical trials to affect performance, or individuals must use both EFOA and IFOA in the process of creating imagery of the environment and movements, which may obscure the effect of EFOA and IFOA.

Goal conceptualization has distinct effects on spatial and temporal bimanual coordination after left- and right- hemisphere stroke

Perception of task goal influences motor performance and coordination. In bimanual actions, it is unclear how one's perception of task goals influences bimanual coordination and performance in individuals with unilateral stroke. We characterized inter-limb coordination differences in individuals with chronic right- and left-hemisphere damaged (RCVA: n = 24, LCVA: n = 24) stroke and age-matched neurotypical controls (n = 24) as they completed bimanual reaching tasks under distinct goal conditions. In the dual-goal condition, participants reached to move two virtual bricks (cursors) assigned to each hand toward independent targets. In the common-goal condition, they moved a central common virtual brick representing both hands to a single, central target. Spatial and temporal coordination (cross-correlation coefficients of hand velocity and their time-lag), the redundant axis deviations (the hand deviations in the axis orthogonal to the axis along the cursor-target direction), and the contribution ratio of the paretic hand were measured. Compared to the dual-goal condition, reaching actions to the common-goal demonstrated better spatial bimanual coordination in all three participant groups. Temporal coordination was better during common-goal than dual-goal actions only for the LCVA group. Additionally, and novel to this field, sex, as a biological variable, differently influenced movement time and redundant axis deviation in participants with stroke under the common-goal condition. Specifically, female stroke survivors showed larger movements in the redundant axes and, consequently, longer movement times, which was more prominent in the LCVA group. Our results indicate that perception of task goals influences bimanual coordination, with common goal improving spatial coordination in neurotypical individuals and individuals with unilateral stroke and providing additional advantage for temporal coordination in those with LCVA. Sex influences bimanual performance in stroke survivors and needs to be considered in future investigations.

Prognostic impact of peripheral blood WT1 mRNA dynamics in patients with acute myeloid leukemia treated with venetoclax combination therapy

BACKGROUND

Wilms' tumor gene 1 (WT1) mRNA quantification is a useful marker of measurable residual disease in acute myeloid leukemia (AML). However, whether monitoring the WT1 mRNA levels may predict the outcome of venetoclax (VEN) combination therapy in AML is not reported. This study aims to elucidate whether WT1 mRNA dynamics could predict long-term prognosis.

METHODS

33 patients with untreated or relapsed/refractory AML evaluated for peripheral blood WT1 dynamics in VEN combination therapy were analyzed.

RESULTS

The median age was 73 years (range 39-87). Azacitidine was combined with VEN in 91% of patients. Overall, the median overall survival (OS) was 334 days (95% CI 210-482), and the complete remission (CR) plus CR with incomplete hematologic recovery rate was 59%. A 1-log reduction of WT1 mRNA values by the end of cycle 2 of treatment was associated with significantly better OS and event-free survival (EFS) (median OS 482 days vs. 237 days, p = 0.049; median EFS 270 days vs. 125 days, p = 0.02). The negativity of post-treatment WT1 mRNA value during the treatment was associated with significantly better OS and EFS (median OS 482 days vs. 256 days, p = 0.02; median EFS not reached vs. 150 days, p = 0.005). Multivariate analysis confirmed the significance of these two parameters as strong EFS predictors (HR 0.26, p = 0.024 and HR 0.15, p = 0.013, respectively). The increase in WT1 mRNA values was correlated with relapse.

CONCLUSION

This study demonstrates that WT1 mRNA dynamics can be a useful marker for assessing long-term prognosis of VEN combination therapy for AML.

Characteristics of macrophage aggregates prepared by rotation culture and their response to polymeric materials

Understanding the interaction between macrophages and biomaterials is important for the creation of new biomaterials and the development of technologies to control macrophage function. Since macrophages are strongly adhesive, caution is required when performing in vitro evaluations. Similarly, when THP-1 cells, macrophage precursor cells, are differentiated into macrophages using phorbol-12-myristate-13-acetate (PMA), it becomes difficult to detach them from the adherent substrate, which has been a problem on investigation of immunological responses to biomaterials. In this study, the interaction of THP-1 cell-differentiated macrophages with biomaterials was analyzed based on a new method of seeding THP-1 cells. THP-1 cells were cultured in static and rotation culture without and with PMA. In undifferentiated THP-1 cells, there was no change in cellular function between static and rotation cultures. In rotation culture with PMA, THP-1 cells differentiated and formed macrophage aggregates. IL-1β and MRC1 expression in macrophage aggregates was examined after differentiation and M1/M2 polarization. Macrophage aggregates in rotation culture tended to be polarized toward M2 macrophages compared with those in static culture. In the evaluation of the responses of macrophage aggregates to several kinds of polymeric materials, macrophage aggregates showed different changes in MRC1 expression over time at 30, 50, and 70 rpm. Rotation speed of 30 rpm was considered most appropriate condition in that it gave stable results with the same trend as obtained with static culture. The use of macrophage aggregates obtained by rotational culture is expected to provide new insights into the evaluation of inflammatory properties of biomaterials.

Do attentional focus cues affect the type or number of explicit rules? Proof of concepts of the self-invoking trigger or explicit knowledge hypotheses

Internal focus has been shown to be detrimental to performance by disrupting the motor system, whereas external focus enhances performance by promoting automaticity. One hypothesis, which explains the underlying mechanism of the disruption of the motor system, proposes that internal focus affects the type of thoughts (explicit rules) by invoking self-conscious, evaluative thoughts (McKay et al., 2015). In contrast, another hypothesis proposes that internal focus increases the number of explicit rules, loading working memory (Poolton et al., 2006). To examine the competing hypotheses, neurotypical young adults (22.98 ± 4.46 years old, n = 20 males, n = 40 females) were assigned to one of three groups: external focus (n = 20), internal focus (n = 20), and control (n = 20) groups, and practiced a reciprocal aiming task for two days with retention/transfer tests. Between trials, participant's thoughts were evaluated by an open-ended questionnaire. The type of explicit rules was analyzed using a chi-square test, and the number of explicit rules was analyzed using a mixed-effect Poisson regression. The results showed that external focus resulted in a greater proportion of explicit rules about the task and a lesser proportion of self-evaluative thoughts. The number of explicit rules did not differ between groups. Our results suggest that external focus may strengthen focus on task-relevant features, while internal focus moves people's attention away from important features, potentially explaining why the motor system is disrupted by internal focus.

Impact of the coronavirus disease 2019 pandemic on gastric and colorectal cancer surgeries: a multicenter epidemiologic study from the Kinki region of Japan

The coronavirus disease 2019 pandemic affected cancer surgeries and advanced cancer diagnoses; however, the trends in patient characteristics in medical institutions during this time, and the surgical approaches used are unclear. We investigated the impact of the pandemic on gastric and colorectal cancer surgeries in the Kinki region of Japan. We grouped 1688 gastric and 3493 colorectal cancer surgeries into three periods: "pre-pandemic" (April 2019-March 2020), "pandemic 1" (April 2020-March 2021), and "pandemic 2" (April 2021-September 2021), to investigate changes in the number of surgeries, patient characteristics, surgical approaches, and cancer progression after surgery. Gastric and colorectal cancer surgeries decreased from the pre-pandemic levels, by 20% and 4%, respectively, in pandemic 1, and by 31% and 19%, respectively, in pandemic 2. This decrease had not recovered to pre-pandemic levels by September, 2021. Patient characteristics, surgical approaches, and cancer progression of gastric and colorectal surgeries did not change remarkably as a result of the coronavirus disease 2019 pandemic.

Immunomodulators after the discontinuation of anti-tumor necrosis factor-alpha antibody treatment and relapse in ulcerative colitis: A multicenter cohort study

BACKGROUND AND AIM

Strategies to reduce relapse using immunomodulators (IMs) after discontinuing anti-tumor necrosis factor-alpha (TNF-α) antibody treatment are controversial in patients with ulcerative colitis (UC). In this study, we assessed the association between IMs after discontinuing anti-TNF-α antibody treatment and relapse in patients with UC.

METHODS

This retrospective, multicenter cohort study included 257 patients with UC in clinical remission. These patients discontinued anti-TNF-α antibody treatment between June 2010 and March 2019 and were followed up until March 2020. We evaluated the differences in relapse rates between patients with IMs (IM group) and those without IMs (non-IM group) after discontinuing the treatment. Relapse was defined as further undergoing an induction treatment or colectomy. Cox proportional hazards models adjusted for confounders were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for relapse. Exploratory analyses were performed to identify other factors that could predict relapse.

RESULTS

During the median follow-up period of 22 months (interquartile range: 10-41), 114 relapses occurred: 42/100 (42.0%) in the IM group and 72/157 (45.9%) in the non-IM group. In the multivariable analysis, IMs were not associated with relapse (HR, 0.95 [95% CI, 0.64-1.41]). In the exploratory analyses, discontinuation due to side effects (HR, 1.83 [95% CI, 1.18-2.82]) and younger age (HR, 0.99 [95% CI, 0.98-1.00]) predicted relapse.

CONCLUSION

Immunomodulators were not associated with relapse after discontinuing anti-TNF-α antibody treatment in patients with UC. Careful patient follow-up is needed when discontinuing due to side effects or when the patient is of a younger age at the time of discontinuation.

Risk of severe COVID-19 in unvaccinated patients during the period from wild-type to Omicron variant: real-world evidence from Japan

BACKGROUND

Many studies have reported that the Omicron variant is less pathogenic than the Delta variant and the wild-type. Epidemiological evidence regarding the risk of severe COVID-19 from the wild-type to the Omicron variant has been lacking.

METHODS

Study participants were COVID-19 patients aged 18 and older without previous COVID-19 infection who were notified to the Nara Prefecture Chuwa Public Health Center from January 2020 to March 2023, during the periods from the wild-type to the Omicron variant. The outcome variable was severe COVID-19 (i.e., ICU admission or COVID-19-related death). The explanatory variable was SARS-CoV-2 variant type or the number of COVID-19 vaccinations. Covariates included gender, age, risk factors for aggravation, and the number of general hospital beds per population. The generalized estimating equations of negative binomial regression models were used to estimate the adjusted incidence proportion (AIP) with 95% confidence interval (CI) for severe COVID-19.

RESULTS

Among 77,044 patients included in the analysis, 14,556 (18.9%) were unvaccinated and 520 (0.7%) developed severe COVID-19. Among unvaccinated patients, the risk of severe COVID-19 increased in the Alpha/Delta variants and decreased in the Omicron variant compared to the wild-type (AIP [95% CI] was 1.55 [1.06-2.27] in Alpha/Delta and 0.25 [0.15-0.40] in Omicron), but differed by age. Especially in patients aged ≥80, there was no significant difference in the risk of severe COVID-19 between the wild-type and the Omicron variant (AIP [95% CI] = 0.59 [0.27-1.29]). Regarding the preventive effect of vaccines, among all study participants, the number of vaccinations was significantly associated with the prevention of severe COVID-19, regardless of variant type. After stratified analyses by age, patients aged ≥80 remained a significant association for all variant types. On the other hand, the number of vaccinations had no association in Omicron BA.5 of patients aged 18-64.

CONCLUSIONS

Patients aged ≥80 had less reduction in risk of severe COVID-19 during the Omicron variant period, and a greater preventive effect of vaccines against severe COVID-19, compared to younger people. Our findings suggest that booster vaccination is effective and necessary for older people, especially aged ≥80.

Laboratory Study of Collisionless Magnetic Reconnection

A concise review is given on the past two decades' results from laboratory experiments on collisionless magnetic reconnection in direct relation with space measurements, especially by the Magnetospheric Multiscale (MMS) mission. Highlights include spatial structures of electromagnetic fields in ion and electron diffusion regions as a function of upstream symmetry and guide field strength, energy conversion and partitioning from magnetic field to ions and electrons including particle acceleration, electrostatic and electromagnetic kinetic plasma waves with various wavelengths, and plasmoid-mediated multiscale reconnection. Combined with the progress in theoretical, numerical, and observational studies, the physics foundation of fast reconnection in collisionless plasmas has been largely established, at least within the parameter ranges and spatial scales that were studied. Immediate and long-term future opportunities based on multiscale experiments and space missions supported by exascale computation are discussed, including dissipation by kinetic plasma waves, particle heating and acceleration, and multiscale physics across fluid and kinetic scales.

Acute Myeloid Leukemia Harboring the t(16;21)(p11;q22) Translocation Treated With Venetoclax Plus Azacitidine After Cord Blood Transplantation

A 62-year-old female was diagnosed with acute myeloid leukemia (AML) with t(16;21)(p11;q22). She achieved complete hematological remission after induction therapy and underwent umbilical cord blood stem cell transplantation (CBT). At 150 days after the CBT, a bone marrow examination revealed relapse. We treated the patient with venetoclax plus azacitidine as salvage therapy. After five cycles of venetoclax and azacitidine therapy, the patient died due to disease progression. The prognosis of AML with t(16;21)(p11;q22) is very poor owing to the high rate of early relapse even after hematopoietic stem cell transplantation. Therefore, a novel therapeutic approach is required to improve patient outcomes.

Mechanoregulation of Osteoclastogenesis-Inducing Potentials of Fibrosarcoma Cell Line by Substrate Stiffness

A micro-physiological system is generally fabricated using soft materials, such as polydimethylsiloxane silicone (PDMS), and seeks an inflammatory osteolysis model for osteoimmunological research as one of the development needs. Microenvironmental stiffness regulates various cellular functions via mechanotransduction. Controlling culture substrate stiffness may help spatially coordinate the supply of osteoclastogenesis-inducing factors from immortalized cell lines, such as mouse fibrosarcoma L929 cells, within the system. Herein, we aimed to determine the effects of substrate stiffness on the osteoclastogenesis-inducing potential of L929 cells via cellular mechanotransduction. L929 cells showed increased expression of osteoclastogenesis-inducing factors when cultured on type I collagen-coated PDMS substrates with soft stiffness, approximating that of soft tissue sarcomas, regardless of the addition of lipopolysaccharide to augment proinflammatory reactions. Supernatants of L929 cells cultured on soft PDMS substrates promoted osteoclast differentiation of the mouse osteoclast precursor RAW 264.7 by stimulating the expression of osteoclastogenesis-related gene markers and tartrate-resistant acid phosphatase activity. The soft PDMS substrate inhibited the nuclear translocation of YES-associated proteins in L929 cells without reducing cell attachment. However, the hard PDMS substrate hardly affected the cellular response of the L929 cells. Our results showed that PDMS substrate stiffness tuned the osteoclastogenesis-inducing potential of L929 cells via cellular mechanotransduction.

What can surgeons do to prevent job leave soon after cancer diagnosis? A brief report on colorectal cancer survivors in Japan

PURPOSE

Colorectal cancer is one of the most diagnosed cancers in Japan and the number of cancer survivors has increased. Work-related issues of cancer survivors have been investigated in relation to occupational health, and sufficient evidence in clinical practice is needed to support this. This study aimed to obtain the relevant information, intending to support the employment of patients with colorectal cancer for clinical settings.

METHODS

We conducted a prospective, multicenter cohort study, which included patients who underwent surgery with clinical stage I-III colorectal cancer. An electronic survey was used at the time of hospital admission to collect the patients' occupational information, including job resignation soon after cancer diagnosis. A cross-sectional analysis was performed to evaluate the patients' employment situations.

RESULTS

Of 129 eligible patients, 46 (36%) were female. Thirty-nine (30%) were self-employed and 72 (56%) worked at small-sized workplaces, which are not obliged to have occupational physicians. Most patients (89%) expressed their desire to return to work, but eight patients (6%) left their jobs soon after being diagnosed with colorectal cancer before undergoing surgery for several reasons stemming from worries about future treatment and its consequences. Multivariable analyses indicated that nonregular employees and the self-employed might be at a disadvantage in keeping their job at diagnosis.

CONCLUSION

Surgeons should address work-related issues for survivorship, which begins at cancer diagnosis and, when available, collaborate with occupational physicians while being mindful that patients working at smaller companies do not have immediate access to occupational physicians.

Stiffness-Tunable Hydrogel-Sandwich Culture Modulates the YAP-Mediated Mechanoresponse in Induced-Pluripotent Stem Cell Embryoid Bodies and Augments Cardiomyocyte Differentiation

Microenvironmental factors, including substrate stiffness, regulate stem cell behavior and differentiation. However, the effects of substrate stiffness on the behavior of induced pluripotent stem cell (iPSC)- derived embryoid bodies (EB) remain unclear. To investigate the effects of mechanical cues on iPSC-EB differentiation, a 3D hydrogel-sandwich culture (HGSC) system is developed that controls the microenvironment surrounding iPSC-EBs using a stiffness-tunable polyacrylamide hydrogel assembly. Mouse iPSC-EBs are seeded between upper and lower polyacrylamide hydrogels of differing stiffness (Young's modulus [E'] = 54.3 ± 7.1 kPa [hard], 28.1 ± 2.3 kPa [moderate], and 5.1 ± 0.1 kPa [soft]) and cultured for 2 days. HGSC induces stiffness-dependent activation of the yes-associated protein (YAP) mechanotransducer and actin cytoskeleton rearrangement in the iPSC-EBs. Moreover, moderate-stiffness HGSC specifically upregulates the mRNA and protein expression of ectoderm and mesoderm lineage differentiation markers in iPSC-EBs via YAP-mediated mechanotransduction. Pretreatment of mouse iPSC-EBs with moderate-stiffness HGSC promotes cardiomyocyte (CM) differentiation and structural maturation of myofibrils. The proposed HGSC system provides a viable platform for investigating the role of mechanical cues on the pluripotency and differentiation of iPSCs that can be beneficial for research into tissue regeneration and engineering.

Long-term results of a phase 2 study of neoadjuvant chemotherapy with molecularly targeted agents for locally advanced rectal cancer

BACKGROUND

We previously reported the feasibility and efficacy of neoadjuvant chemotherapy without radiotherapy for locally advanced rectal cancer. Here, we report the results of a long-term follow-up study.

METHODS

This was a multi-institutional, prospective phase 2 study of patients with locally advanced rectal cancer. Patients received neoadjuvant chemotherapy with molecularly targeted agents before undergoing total mesorectal excision. Six cycles of modified FOLFOX (mFOLFOX6) with bevacizumab were administered to KRAS-mutant patients, and mFOLFOX6 with cetuximab was administered to KRAS-wild-type patients. Here, we report the secondary end points of overall survival, relapse-free survival, and local recurrence rate.

RESULTS

Sixty patients were enrolled in this study. R0 resection was achieved in 98.3% (59/60) patients, and pathological complete response was achieved in 16.7% (10/60) patients. After a median follow-up of 5.4 years, the 5 year overall survival was 81.6%, the 5 year relapse-free survival was 71.7%, and the 5 year local recurrence rate was 12.6%. None of the patients who achieved pathological complete response developed recurrence within 5 years.

CONCLUSIONS

The use of molecularly targeted agents in the neoadjuvant setting for locally advanced rectal cancer has an acceptable prognosis.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Identification of Senescent Cells in Peri-Implantitis and Prevention of Mini-Implant Loss Using Senolytics

Peri-implantitis is a disease that causes the detachment of orthodontic mini-implants. Recently, stress-induced senescent cells have been reported to be involved in various inflammatory diseases. Senescent cell-eliminating drugs, termed "senolytics", can improve the symptoms of such diseases. However, the relationship between peri-implantitis and senescent cells remains unclear. In this study, we evaluated the presence of senescent cells in a rat peri-implantitis model developed with a gum ring. The effect on bone resorption and implant loss was also investigated with and without senolytics (Dasatinib and Quercetin). The number of senescence markers (p19, p21, and p16) was found to increase, and implant detachment occurred in 24 days. After the administration of senolytics, the number of senescence markers decreased and implant detachment was inhibited. This study suggests that senescent cells aggravate peri-implantitis and senolytic administration latently reduces implant loss by inhibiting senescence-related mechanisms.

Association between vaccination status and severe health consequences among community-dwelling COVID-19 patients during Omicron BA.1/BA.2 and BA.5-predominant periods in Japan

BACKGROUND

Many previous studies have reported that COVID-19 vaccine effectiveness decreased over time and declined with newly emerging variants. However, there are few such studies in Japan. Using data from a community-based retrospective study, we aimed to assess the association between vaccination status and severe COVID-19 outcomes caused by the Omicron variant, considering the length of time since the last vaccination dose.

METHODS

We included all persons aged ≥12 diagnosed with COVID-19 by a doctor and notified to the Chuwa Public Health Center of Nara Prefectural Government during the Omicron BA.1/BA.2 and BA.5-predominant periods in Japan (January 1 to September 25, 2022). The outcome variable was severe health consequences (SHC) (i.e., COVID-19-related hospitalization or death). The explanatory variable was vaccination status of the individuals (i.e., the number of vaccinations and length of time since last dose). Covariates included gender, age, risk factors for aggravation, and the number of hospital beds per population. Using the generalized estimating equations of the multivariable Poisson regression models, we estimated the cumulative incidence ratio (CIR) and 95% confidence interval (CI) for SHC, with stratified analyses by period (BA.1/BA.2 or BA.5) and age (65 and older or 12-64 years).

RESULTS

Of the 69,827 participants, 2,224 (3.2%) had SHC, 12,154 (17.4%) were unvaccinated, and 29,032 (41.6%) received ≥3 vaccine doses. Regardless of period or age, there was a significant dose-response relationship in which adjusted CIR for SHC decreased with an increased number of vaccinations and a longer time since the last vaccination. On the one hand, in the BA.5 period, those with ≥175 days after the third dose had no significant difference in people aged 65 and older (CIR 0.77; 95% CI, 0.53-1.12), but significantly lower CIR for SHC in people aged 12-64 (CIR 0.47; 95% CI, 0.26-0.84), compared with those with ≥14 days after the second dose.

CONCLUSION

A higher number of vaccinations were associated with lower risk of SHC against both BA.1/BA.2 and BA.5 sublineages. Our findings suggest that increasing the number of doses of COVID-19 vaccine can prevent severe COVID-19 outcomes, and that a biannual vaccination is recommended for older people.

Association between vaccination status and COVID-19-related health outcomes among community-dwelling COVID-19 patients in Nara, Japan

BACKGROUND

Many previous studies have reported COVID-19 vaccine effectiveness, but there are few studies in Japan. This community-based, retrospective observational study investigated the association between vaccination status and COVID-19-related health outcomes in COVID-19 patients by SARS-CoV-2 variant type.

METHODS

The study participants were 24,314 COVID-19 patients aged 12 or older whose diagnoses were reported to the Nara Prefecture Chuwa Public Health Center from April 2021 to March 2022, during periods when the alpha, delta, and omicron variants of COVID-19 were predominant. The outcome variables were severe health consequences (SHC) (i.e., ICU admission and COVID-19-related death), hospitalization, and extension of recovery period. The explanatory variable was vaccination status at least 14 days prior to infection. Covariates included gender, age, population size, the number of risk factors for aggravation, and the number of symptoms at diagnosis. The generalized estimating equations of the multivariable Poisson regression models were used to estimate the adjusted incidence proportion (AIP) and 95% confidence interval (CI) for each health outcome. We performed stratified analyses by SARS-CoV-2 variant type, but the association between vaccination status and COVID-19-related health outcomes was stratified only for the delta and omicron variants due to the small number of vaccinated patients during the alpha variant.

RESULTS

Of the 24,314 participants, 255 (1.0%) had SHC; of the 24,059 participants without SHC, 2,102 (8.7%) were hospitalized; and of the 19,603 participants without SHC, hospitalization, and missing data on recovery period, 2,960 (15.1%) had extension of recovery period. Multivariable Poisson regression models showed that regardless of SARS-CoV-2 variant type or health outcome, those who received two or more vaccine doses had significantly lower risk of health outcomes than those who did not receive the vaccine, and there was a dose-response relationship in which the AIP for health outcomes decreased with an increased number of vaccinations.

CONCLUSION

A higher number of vaccinations were associated with lower risk of COVID-19-related health outcomes, not only in the delta variant but also in the omicron variant. Our findings suggest that increasing the number of COVID-19 vaccine doses can prevent severe disease and lead to early recovery of patients not requiring hospitalization.

Neuromotor changes in participants with a concussion history can be detected with a custom smartphone app

Neuromotor dysfunction after a concussion is common, but balance tests used to assess neuromotor dysfunction are typically subjective. Current objective balance tests are either cost- or space-prohibitive, or utilize a static balance protocol, which may mask neuromotor dysfunction due to the simplicity of the task. To address this gap, our team developed an Android-based smartphone app (portable and cost-effective) that uses the sensors in the device (objective) to record movement profiles during a stepping-in-place task (dynamic movement). The purpose of this study was to examine the extent to which our custom smartphone app and protocol could discriminate neuromotor behavior between concussed and non-concussed participants. Data were collected at two university laboratories and two military sites. Participants included civilians and Service Members (N = 216) with and without a clinically diagnosed concussion. Kinematic and variability metrics were derived from a thigh angle time series while the participants completed a series of stepping-in-place tasks in three conditions: eyes open, eyes closed, and head shake. We observed that the standard deviation of the mean maximum angular velocity of the thigh was higher in the participants with a concussion history in the eyes closed and head shake conditions of the stepping-in-place task. Consistent with the optimal movement variability hypothesis, we showed that increased movement variability occurs in participants with a concussion history, for which our smartphone app and protocol were sensitive enough to capture.

Effectiveness of educational program on systematic and extensive palliative care in cancer patients for pharmacists

BACKGROUND AND PURPOSE

Continuing education is essential for pharmacists to acquire latest knowledge. Our previously established educational program for pharmacists on the systematic and extensive palliative care of cancer patients was evaluated for its educational effectiveness in one urban prefecture. However, whether the same learning effect can be achieved when a program is expanded from one urban prefecture to multiple rural prefectures is unclear. In this study, we examined whether the continuing education program would be useful to pharmacists, even if the scale was expanded.

EDUCATIONAL ACTIVITY AND SETTING

With the aim of correcting educational disparities in the region, pharmacists living in nine prefectures in the Kyushu area underwent a systematic and extensive palliative care educational program for six days (with 24 topics in total). They were administered a questionnaire before and after each topic to evaluate their level of understanding.

FINDINGS

The level of understanding of the 24 topics in the program that palliative care pharmacists underwent, from "basic knowledge" to "clinical application," significantly improved (P < .01).

SUMMARY

The educational program for pharmacists is useful even when implemented on a larger scale. We believe that our efforts are important for improving community-based care.

Correction of large jawbone defect in the mouse using immature osteoblast-like cells and a 3D polylactic acid scaffold

Bone tissue engineering has been developed using a combination of mesenchymal stem cells (MSCs) and calcium phosphate-based scaffolds. However, these complexes cannot regenerate large jawbone defects. To overcome this limitation of MSCs and ceramic scaffolds, a novel bone regeneration technology must be developed using cells possessing high bone forming ability and a scaffold that provides space for vertical bone augmentation. To approach this problem in our study, we developed alveolar bone-derived immature osteoblast-like cells (HAOBs), which have the bone regenerative capacity to correct a large bone defect when used as a grafting material in combination with polylactic acid fibers that organize the 3D structure and increase the strength of the scaffold material (3DPL). HAOB-3DPL constructs could not regenerate bone via xenogeneic transplantation in a micromini pig alveolar bone defect model. However, the autogenic transplantation of mouse calvaria-derived immature osteoblast-like cells (MCOBs) isolated using the identical protocol for HAOBs and mixed with 3DPL scaffolds successfully regenerated the bone in a large jawbone defect mouse model, compared to the 3DPL scaffold alone. Nanoindentation analysis indicated that the regenerated bone had a similar micromechanical strength to native bone. In addition, this MCOB-3DPL regenerated bone possesses osseointegration ability wherein a direct structural connection is established with the titanium implant surface. Hence, a complex formed between a 3DPL scaffold and immature osteoblast-like cells such as MCOBs represents a novel bone tissue engineering approach that enables the formation of vertical bone with the micromechanical properties required to treat large bone defects.

Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy

BACKGROUND

Pancreaticojejunal (PJ) anastomosis occasionally fails several months after pancreaticoduodenectomy (PD) with Child reconstruction and can ultimately result in a late-onset complete pancreaticocutaneous fistula (Lc-PF). Since the remnant pancreas is an isolated segment, surgical intervention is necessary to create internal drainage for the pancreatic juice; however, surgery at the previous PJ anastomosis site is technically challenging even for experienced surgeons. Here we describe a simple surgical procedure for Lc-PF, termed redo PJ anastomosis, which was developed at our facility.  METHODS: Between January 2008 and December 2020, six consecutive patients with Lc-PF after PD underwent a redo PJ anastomosis, and the short- and long-term clinical outcomes have been evaluated. The abdominal cavity is carefully dissected through a 10-cm midline skin incision, and the PJ anastomosis site is identified using a percutaneous drain through the fistula tract as a guide, along with the main pancreatic duct (MPD) stump on the pancreatic stump. Next, the pancreatic stump is deliberately immobilized from the dorsal plane to prevent injury to the underlying major vessels. After fixing a stent tube to both the MPD and the Roux-limb using two-sided purse-string sutures, the redo PJ anastomosis is completed using single-layer interrupted sutures. Full-thickness pancreatic sutures are deliberately avoided by passing the needle through only two-thirds of the anterior side of the pancreatic stump.

RESULTS

The redo PJ anastomosis was performed without any intraoperative complications in all cases. The median intraoperative bleeding and operative time were 71 (range 10-137) mL and 123 (range 56-175) min, respectively. Even though a new mild pancreatic fistula developed postoperatively in all cases, it could be conservatively treated within 3 weeks, and no other postoperative complications were recorded. During the median follow-up period of 92 (range 12-112) months, no complications at the redo PJ anastomosis site were observed.

CONCLUSIONS

This research shows that the redo PJ anastomosis for Lc-PF we developed is a safe, feasible, and technically no demanding procedure with acceptable short- and long-term clinical outcomes. This procedure has the potential to become the preferred treatment strategy for Lc-PF after PD.

Titanium Nanosurface with a Biomimetic Physical Microenvironment to Induce Endogenous Regeneration of the Periodontium

The periodontium supports the teeth by dentoalveolar fibrous joints that serve unique oral functions. Endogenous regeneration of the periodontium around artificial teeth (dental implants) provides a cost-effective solution for the extension of healthy life expectancy but remains a challenge in regenerative medicine. Biomimetics can create smart biomaterials that tune endogenous cells at a tissue-material interface. Here, we created a smart titanium nanosurface mimicking the surface nanotopography and micromechanical properties of the tooth root cementum (TRC), which is essential for the induction of dentoalveolar fibrous joints to regenerate the periodontium. After transplantation into the rat renal capsule, only the titanium artificial tooth with the TRC-mimetic nanosurface formed a complex dentoalveolar fibrous joint structure, with bone tissue, periodontal ligament (PDL), and TRC, in the decellularized jawbone matrix. TRC-mimetic titanium implants induce the formation of functional periodontium, even in a jawbone implantation model, which generally causes osseointegration (ankyloses). In human PDL cells, TRC analogousness in the surface mechanical microenvironment regulates matrix mineralization through bone sialoprotein expression and phosphorus metabolism, which are critical for cementogenesis. Therefore, the titanium nanosurfaces with nanotopographical and mechanical microenvironments mimicking the TRC surface induce dentoalveolar fibrous joints for periodontal regeneration by interfacial tuning of endogenous cells.

Practice-Not Task Difficulty-Mediated the Focus of Attention Effect on a Speed-Accuracy Tradeoff Task

External focus (attention to the movement effect) has been found effective in motor performance and learning. However, while some investigators have suggested that the effect of attentional focus varies with task difficulty, others reported external focus benefits regardless of difficulty. We hypothesized that attentional focus effects would vary with practice, due to changes in the individual's processing efficiency. We had three 20-person participant groups (external focus instructions, internal focus instructions, control) practice three difficulty levels of a Fitts reciprocal tapping task over two days. Participants in the external/internal focus groups were instructed to "mentally focus on moving the pen/your hand as fast and accurately as possible," while control participants were instructed to "mentally focus only on doing your best to achieve the task goal." We then analyzed the effect of attentional focus by task difficulty at the initial performance (the beginning of the practice) and after learning (the retention/transfer phase), using movement time (MT) and number of error taps (Err) as performance measures. The internal focus group made more errors than the control group only at the retention/transfer phase. We found no error differences between the external and internal focus groups, and there were no MT differences between any groups. Our primary hypothesis about the differential effect of attentional focus by practice was supported. The attentional focus effect on Err differed in the retention/transfer phase from the immediate phase, suggesting that practice mediated the attentional focus effect. We discuss how information theory may supplement understanding of attentional focus interventions in motor skill acquisition.

Prevalence of Hoarseness and Its Association with Severity of Dysphagia in Patients with Sarcopenic Dysphagia

OBJECTIVES

To investigate the prevalence of hoarseness and its association with the severity of dysphagia in patients with sarcopenic dysphagia.

DESIGN

Cross-sectional study using the Japanese sarcopenic dysphagia database.

SETTING

19 hospitals including 9 acute care hospitals, 8 rehabilitation hospitals, 2 long-term care hospitals, and 1 home visit rehabilitation team.

PARTICIPANTS

287 patients with sarcopenic dysphagia, aged 20 years and older.

MEASUREMENTS

Sarcopenic dysphagia was diagnosed using a reliable and validated diagnostic algorithm for the condition. The presence and characteristics of hoarseness classified as breathy, rough, asthenic, and strained were assessed. The prevalence of hoarseness and the relationship between hoarseness and Food Intake LEVEL Scale (FILS) were examined. Order logistic regression analysis adjusted for age, sex, naso-gastric tube, and handgrip strength was used to examine the relationship between hoarseness and FILS at baseline and at follow-up.

RESULTS

The mean age was 83 ± 10 years. Seventy-four (26%) patients had hoarseness, while 32 (11%), 20 (7%), 22 (8%), and 0 (0%) patients had breathy, rough, asthenic, and strained hoarseness, respectively. Median FILS at the initial evaluation was 7 (interquartile range, 5-8). Hoarseness (β=0.747, 95% confidence intervals= 0.229, 1.265, p=0.005), age, sex, naso-gastric tube, and handgrip strength were associated independently with baseline FILS, while hoarseness (β=0.213, 95% confidence intervals= -0.324, 0.750, p=0.438) was not associated independently with the FILS at follow-up.

CONCLUSIONS

Hoarseness was associated with the severity of dysphagia at baseline, however not a prognostic factor for sarcopenic dysphagia. Resistance training of swallowing and respiratory muscles and voice training as part of rehabilitation nutrition might be useful for treating sarcopenic dysphagia.

Performance of Idylla™ RAS-BRAF mutation test for formalin-fixed paraffin-embedded tissues of colorectal cancer

BACKGROUND

The Biocartis Idylla^™ platform is a fully automated, real-time PCR-based diagnostic system. The Idylla^™ KRAS and NRAS-BRAF Mutation Tests have been developed for the qualitative detection of mutations in KRAS, NRAS and BRAF genes, facilitating the genomic profiling of patients with colorectal cancer. The aim of the present study was to evaluate clinical performances of these tests in Japan.

METHODS

The RAS and BRAF mutation statuses of 253 formalin-fixed paraffin-embedded (FFPE) colorectal cancer tissues were analyzed using the Investigational Use Only Idylla^™ KRAS Mutation Test and the Idylla^™ NRAS-BRAF Mutation Test and an in vitro diagnostics (IVD) kit (MEBGEN RASKET^™-B kit).

RESULTS

The success rate for obtaining a valid mutational data without retest of the Idylla tests was 97.6% (247/253): 111 KRAS mutations (43.8%), 9 NRAS mutations (3.6%), and 36 BRAF V600E mutations (14.2%) were detected using the Idylla tests. Compared with the MEBGEN RASKET-B results, the positive concordance rate was 97.4%, the negative concordance rate was 95.7%, and the overall concordance rate was 95.3% (κ = 0.919, 95% CI 0.871-0.967). The average turnaround time to Idylla^™ KRAS and NRAS-BRAF Mutation Test was 5.6 working days (range: 3-11 days).

CONCLUSION

This result demonstrates a high concordance between the Idylla^™ KRAS and NRAS-BRAF Mutation Tests and an existing IVD kit. In this manner, the Idylla^™ mutation tests were validated for the detection of clinically significant KRAS, NRAS, and BRAF mutations in FFPE samples from colorectal cancer patients.

Pebbles and sand on asteroid (162173) Ryugu: In situ observation and particles returned to Earth

The Hayabusa2 spacecraft investigated the C-type (carbonaceous) asteroid (162173) Ryugu. The mission performed two landing operations to collect samples of surface and subsurface material, the latter exposed by an artificial impact. We present images of the second touchdown site, finding that ejecta from the impact crater was present at the sample location. Surface pebbles at both landing sites show morphological variations ranging from rugged to smooth, similar to Ryugu's boulders, and shapes from quasi-spherical to flattened. The samples were returned to Earth on 6 December 2020. We describe the morphology of >5 grams of returned pebbles and sand. Their diverse color, shape, and structure are consistent with the observed materials of Ryugu; we conclude that they are a representative sample of the asteroid.

Altered Rheological Properties of Saliva with Aging in Mouse Sublingual Gland

Mucin in saliva plays a critical role in the hydration and lubrication of the oral mucosa by retaining water molecules, and its impaired function may be associated with hyposalivation-independent xerostomia. Age-dependent effects on salivary gland function and rheological properties of secreted saliva are not fully understood as aging is a complex and multifactorial process. We aimed to evaluate age-related changes in the rheological properties of saliva and elucidate the underlying mechanism. We performed ex vivo submandibular gland (SMG) and sublingual gland (SLG) perfusion experiments to collect saliva from isolated glands of young (12 wk old) and aged (27 mo old) female C57BL/6J mice and investigate the rheological properties by determining the spinnbarkeit (viscoelasticity). While fluid secretion was comparable in SMG and SLG of both mice, spinnbarkeit showed a significant decrease in SLG saliva of aged mice than that of young mice. There were no significant differences in GalNAc concentration between young and aged SLG saliva. Liquid chromatography/tandem mass spectrometry analysis of SLG saliva revealed that (Hex)₁ (HexNAc)₁ (NeuAc)₁ at m/z 793.31 was the most abundant O-glycan structure in SLG saliva commonly detected in both mice. Lectin staining of salivary gland tissue showed that SLG stained strongly with Maackia amurensis lectin II (MAL II) while Sambucus nigra agglutinin (SNA) stained little, if any, SLG. The messenger RNA expression of St3gal1 that encodes an α-2,3 sialic acid sialyltransferase SIAT4-A showed a decrease in SLG of aged mice, confirmed by a Western blot analysis. Lectin blot analysis in SLG saliva revealed that the relative signal intensity detected by MAL II was significantly lower in aged SLG. Our results suggest that spinnbarkeit decreases in SLG of aging mice due to downregulation of sialic acid linked to α-2,3 sialic acid sialyltransferase expression.

Factors Associated with Increased Caregiver Burden of Informal Caregivers during the COVID-19 Pandemic in Japan

This study's objective was to explore the association between various factors and the increased caregiver burden of informal caregivers during the COVID-19 pandemic. On February, 2021, 700 informal caregivers completed an online survey. We assessed the change in caregiver burden during the COVID-19 pandemic. Among all caregiver participants, 287 (41.0%) complained of an increased caregiver burden due to the COVID-19 pandemic. The factors associated with increased caregiver burden were depressive symptoms in caregivers [odds ratio (OR), 2.20; 95% confidence interval (CI), 1.50-3.23], dementia (OR, 2.48; 95%CI, 1.07-5.73) and low Barthel Index scores (OR, 2.01; 95%CI, 1.39-2.90) in care receivers, care days (OR, 1.09; 95%CI, 1.01-1.17) and times (OR, 1.06; 95%CI, 1.01-1.10), and use of home care service (OR, 1.46; 95%CI, 1.01-2.10) and visiting care service (OR, 1.71; 95%CI, 1.20-2.45). These findings suggest we need to pay attention to the physical and mental health of both the care receivers and caregivers.

Rapid and efficient generation of cartilage pellets from mouse induced pluripotent stem cells by transcriptional activation of BMP-4 with shaking culture

Induced pluripotent stem cells (iPSCs) offer an unlimited source for cartilage regeneration as they can generate a wide spectrum of cell types. Here, we established a tetracycline (tet) controlled bone morphogenetic protein-4 (BMP-4) expressing iPSC (iPSC-Tet/BMP-4) line in which transcriptional activation of BMP-4 was associated with enhanced chondrogenesis. Moreover, we developed an efficient and simple approach for directly guiding iPSC-Tet/BMP-4 differentiation into chondrocytes in scaffold-free cartilaginous pellets using a combination of transcriptional activation of BMP-4 and a 3D shaking suspension culture system. In chondrogenic induction medium, shaking culture alone significantly upregulated the chondrogenic markers Sox9, Col2a1, and Aggrecan in iPSCs-Tet/BMP-4 by day 21. Of note, transcriptional activation of BMP-4 by addition of tet (doxycycline) greatly enhanced the expression of these genes. The cartilaginous pellets derived from iPSCs-Tet/BMP-4 showed an oval morphology and white smooth appearance by day 21. After day 21, the cells presented a typical round morphology and the extracellular matrix was stained intensively with Safranin O, alcian blue, and type II collagen. In addition, the homogenous cartilaginous pellets derived from iPSCs-Tet/BMP-4 with 28 days of induction repaired joint osteochondral defects in immunosuppressed rats and integrated well with the adjacent host cartilage. The regenerated cartilage expressed the neomycin resistance gene, indicating that the newly formed cartilage was generated by the transplanted iPSCs-Tet/BMP-4. Thus, our culture system could be a useful tool for further investigation of the mechanism of BMP-4 in regulating iPSC differentiation toward the chondrogenic lineage, and should facilitate research in cartilage development, repair, and osteoarthritis.

Titanium surface with nanospikes tunes macrophage polarization to produce inhibitory factors for osteoclastogenesis through nanotopographic cues

Definitive prevention of inflammatory osteolysis around peri-implant bone tissue remains unestablished. M1 macrophages play a key role in the host defense against inflammatory osteolysis, and their polarization depends on cell shape. Macrophage polarization is controlled by environmental stimuli, particularly physicochemical cues and hence titanium nanosurface might tune macrophage polarization and function. This study determined whether titanium nanosurfaces with anisotropically patterned nanospikes regulates macrophage polarization for inhibiting osteoclast differentiation of osteoclast precursors. Alkaline-etching treatment with different protocols created two types of titanium nanosurfaces that had anisotropically patterned nanospikes with high or low distribution density, together with superhydrophilicity and the presence of hydroxyl groups. J774A.1 cells (mouse macrophage-like cell line), cultured on both titanium nanosurfaces, exhibited truly circulated shapes and highly expressed M1, but less M2, markers, without loss of viability. M1-like polarization of macrophages on both titanium nanosurfaces was independent of protein-mediated ligand stimulation or titanium surface hydrophilic or chemical status. In contrast, other smooth or micro-roughened titanium surfaces with little or no nanospikes did not activate macrophages under any culture conditions. Macrophage culture supernatants on both titanium nanosurfaces inhibited osteoclast differentiation of RAW264.7 cells (mouse osteoclast precursor cell line), even when co-incubated with osteoclast differentiation factors. The inhibitory effects on osteoclast differentiation tended to be higher in macrophages cultured on titanium nanosurfaces with denser nanospikes. These results showed that titanium nanosurfaces with anisotropically patterned nanospikes tune macrophage polarization for inhibiting osteoclast differentiation of osteoclast precursors, with nanotopographic cues rather than other physicochemical properties. STATEMENT OF SIGNIFICANCE: Peri-implant inflammatory osteolysis is one of the serious issues for dental and orthopedic implants. Macrophage polarization and function are key for prevention of peri-implant inflammatory osteolysis. Macrophage polarization can be regulated by the biomaterial's surface physicochemical properties such as hydrophilicity or topography. However, there was no titanium surface modification to prevent inflammatory osteolysis through immunomodulation. The present study showed for the first time that the titanium nanosurfaces with anisotropically patterned nanospikes, created by the simple alkali-etching treatment polarized macrophages into M1-like type producing the inhibitory factor on osteoclast differentiation. This phenomenon attributed to nanotopographic cues, but not hydrophilicity on the titanium nanosurfaces. This nanotechnology might pave the way to develop the smart implant surface preventing peri-implant inflammatory osteolysis through immunomodulation.

Association between Inflammation and Functional Outcome in Patients with Sarcopenic Dysphagia

OBJECTIVES

This study aimed to investigate whether inflammation affects the outcome of swallowing ability to improve treatment for sarcopenic dysphagia.

DESIGN

A retrospective observational cohort study was performed using data from the Japanese sarcopenic dysphagia database.

SETTING

The database was constructed using data from 19 hospitals and one home visiting rehabilitation team.

PARTICIPANTS

Patients with sarcopenic dysphagia with measurements of C-reactive protein (CRP) and serum albumin (Alb) were included.

MEASUREMENTS

Patients were assigned to two groups using CRP, Alb, and the Japanese modified Glasgow Prognostic Score (mGPS). The Food Intake LEVEL Scale (FILS) was measured at the times of admission and follow-up (FILS follow-up) to assess swallowing function.

RESULTS

A total of 197 patients were included. Mean or median values of each parameter were as follows: age: 83.8±8.7, Alb: 3.2 ± 0.6 g/dL, CRP: 8.0 [3.0, 29.0] mg/L, mGPS: 1 [1-2], FILS: 7 [6-8], FILS follow-up: 8 [7-8], and duration of follow-up: 57.0 [27.0, 85.0] days. The FILS score at follow-up was significantly lower in the high CRP group (≥ 5.0 mg/L) than in the low CRP group (< 5.0 mg/L) (p = 0.01). Further, the FILS score at follow-up was significantly lower in the high mGPS group (class; 2) than in the low mGPS group (class; 0 and 1) (p = 0.03). In the multiple linear regression analyses without FILS at baseline, CRP and mGPS were independent risk factors for FILS follow-up. When FILS at baseline was entered, CRP and mGPS were not an independent risk factors for FILS follow-up.

CONCLUSIONS

Inflammation could modify the outcome of the patients with sarcopenic dysphagia. Inflammation may be an important risk factor in evaluating patients with sarcopenic dysphagia.

Association between salt intake and long-term mortality in hemodialysis patients: A retrospective cohort study

Background

The association between salt intake and clinical outcomes in hemodialysis patients has been controversial. This study aimed to clarify the association between salt intake and mortality in hemodialysis patients.

Method

The present study included patients who underwent hemodialysis from June 1st 2016 to May 31st 2020. Corrected salt intake by ideal body weight was the main predictor of outcomes. Ideal body weight was calculated assuming that the ideal body mass index is 22 kg/m² for the Japanese population. The multivariate Cox proportional hazards model was used to determine the association between corrected salt intake and mortality, adjusting for potential confounders. The outcomes considered were all-cause mortality and cumulative incidence of cardiovascular events at year 4.

Result

A total of 492 adult patients were enrolled in the study. The mean daily salt intake and corrected salt intake at baseline were 9.5 g/day and 0.17 g/kg/day, respectively. The low corrected salt intake group (< 0.13 g/kg/day) demonstrated the highest 4-year all-cause mortality. No association was observed between corrected salt intake and the cumulative incidence of cardiovascular events. In multivariate Cox proportional hazards analysis, only the group with corrected salt intake of 0.16–0.20 g/kg/day was associated with a decreased hazard risk for all-cause death compared with the low corrected salt intake group.

Conclusion

The present study found that a low salt intake was associated with high all-cause mortality in hemodialysis patients. Reduced long-term survival may be attributed to malnutrition resulting from excessive salt restriction.

A systematic techno-economic approach to decide between continuous and batch operation modes for injectable manufacturing

A comprehensive approach is proposed to systematically determine the optimal mode of operation between continuous and batch injectable manufacturing considering product and market conditions. At the core of this approach are two integrated complete mathematical modules for discrete and continuous injectable manufacturing, which are supplemented with an economic evaluation module that can then be used to explore the impact of all relevant process parameters (e.g., lot-size, number of operators, solubility, product demand, raw material costs). When the developed approach was applied to two case studies, it was found that batch production was preferred at low to moderate solution (raw material) costs. In contrast, at higher solution costs, the preference for batch and continuous production processes changed back and forth as the annual product demand changed. The study also found that continuous production processes became increasingly preferred at medium to large final dosage volumes and a competitive alternative even at moderate solution costs. From a decision-making point of view, batch injectable manufacturing will be preferred over the novel continuous manufacturing technology unless there is a significant economic incentive to overcome the perceived technology risk. The proposed approach is intended as a decision-support tool for pharmaceutical process engineers.

The feasibility of combined resection and subsequent reconstruction of the right hepatic artery in left hepatectomy for cholangiocarcinoma

BACKGROUND

Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma.

MATERIALS AND METHODS

We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction.

RESULTS

Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien-Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan-Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group.

CONCLUSIONS

Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.

Increased and continuous coronary arterial flow was induced by LV uncoupling condition using combined treatment of a microaxial heart pump and venoarterial extracorporeal membrane oxygenation

An emerging therapeutic modality, ECPELLA, which combines a transvalvular microaxial left ventricular (LV) assist device, Impella, and venoarterial membrane oxygenation (VA-ECMO), has been applied for patients with refractory cardiogenic shock. During ECPELLA support, VA-ECMO increases the LV load, whereas the Impella reduces the LV load. Studies reported that coronary perfusion is influenced by LV unloading conditions, and the effective degree of LV unloading to increase the coronary perfusion on ECPELLA support remains to be determined. Here, we reported a cardiogenic shock case whose coronary arterial flow was assessed by transesophageal echocardiography during ECPELLA support. The left anterior descending coronary artery (LAD) peak blood flow velocity and the velocity time integral (VTI) were not significantly increased when blood was ejected from the LV (partial LV unloading). When the LV blood ejection was completely bypassed by Impella confirmed by non-pulsatile aortic pressure with significantly reduced LV pressure with no aortic valve opening (LV uncoupling: no blood ejection from the LV), both peak velocity and VTI of the LAD were markedly increased and the blood flow became continuous throughout the cardiac cycle. Our case suggests that the coronary arterial flow in the injured myocardium is sensitive to degrees of LV unloading on ECPELLA support.

The autonomy and focus of attention strategies under distraction: Frequency and sample entropy analyses in a dynamic balance task

An external focus of attention has been shown to be effective in balance tasks. However, replication in applied settings is limited. The OPTIMAL theory proposes that a combination of autonomy and external focus increases focus to the task goal, and therefore more effective than external focus alone. However, research suggests that the combined effect is limited in discrete skills, and the increased focus effect is only reported by subjective assessment. The present study examined the effect of the combined strategy and its effect of "increased focus" compared to external focus and control groups under distraction. In experiment 1, participants (N = 60) practiced eight 35 s trials on a stabilometer followed by a 10 min-delayed retention test and an auditory distraction transfer test. The combined group chose a tape color to place on a stabilometer and was told to "keep the tapes parallel to the floor," the external focus group was yoked with the combined group, and the control group was told to "do your best". Performance was measured in Root Mean Square Error (RMSE). The increased focus effect was examined by both subjective (distraction score, a question about participants' perceptions) and objective (Mean Power Frequency, MPF, Sample entropy, SampEn) methods. Although participants improved significantly (p < .05), group differences were not observed during retention (p's > 0.05). An increased focus effect of the combined effect was not observed in any variables (p's > 0.05). In experiment 2, the practice duration was extended to replicate previous study designs (i.e., 90s trials; 2 days of practice; 24 h retention test; the number of participants). Consistent with experiment 1, group differences were not evident in RMSE, SampEn, and MPF (p's > 0.05). We suggest that autonomy may be required to be task-relevant, and simply telling to do best may be as useful as external focus or combined strategies in a continuous balance task. Further, the analysis showed that SampEn increased on Day 1 but decreased on Day 2, and MPF decreased within a session, but the average MPF increased by the day. Potential explanations and future directions when utilizing these metrics are discussed.

Comparison of left ventricular pacing performance among pre-shaped guidewires designed for transfemoral-approach transcatheter aortic valve implantation

TAVI is an established therapy for patients with severe aortic stenosis. Rapid or control pacing is necessary for TAVI, and most centers are familiar with right ventricular (RV) pacing. Although there are several reports on the efficacy and safety of LV pacing, they are still few. In addition, LV pacing has not been studied for different LV guidewires. Our aim is to study the effectiveness of left ventricular (LV) pacing and the thresholds of LV guidewires in patients who underwent transcatheter aortic valve implantation (TAVI). We retrospectively analyzed 252 consecutive patients who underwent trans-femoral TAVI (TF-TAVI) with LV pacing in our institute between December 2017 and November 2020. We excluded 48 patients from the total cohort due to TAVI with RV pacing, and the remaining 204 patients were analyzed (52 males, mean age 85 ± 5 years). Among them, 202 patients (99.0%) had successful LV pacing. In the two patients with failed LV pacing, SAFARI2™ Small was used. The CONFIDA™ group (n = 34) showed a significantly lower threshold than the SAFARI2™ group (n = 163) (median 3.0 vs. 5.0 V; P = 1.1 × 10^-7). LV pacing with Lunderquist® was successful in all patients (n = 7). LV pacing in TAVI was an effective and safe strategy. CONFIDA™ wire may be particularly well suited for LV pacing in TAVI.

Diagnostic Accuracy of Diastolic Fractional Flow Reserve for Functional Evaluation of Coronary Stenosis

Background

In the resting conditions, narrowing the window of coronary pressure measurements from the whole cardiac cycle to diastole improves diagnostic performance of coronary pressure–derived physiological index. However, whether this also applies to the hyperemic conditions has not yet been thoroughly evaluated.

Objectives

The purpose of this study was to assess whether diastolic fractional flow reserve (diastolic FFR) has better diagnostic performance in identifying ischemia-causing coronary lesions than conventional FFR in a prospective, multicenter, and independent core laboratory–based environment.

Methods

In this prospective multicenter registry at 29 Japanese centers, we compared the diagnostic performance of FFR, diastolic FFR, resting distal to aortic coronary pressure (Pd/Pa), and diastolic pressure ratio (dPR) using myocardial perfusion scintigraphy (MPS) as the reference standard in 378 patients with single-vessel coronary disease.

Results

Inducible myocardial ischemia was found on MPS in the relevant myocardial territory of the target vessel in 85 patients (22%). In the receiver-operating curve analyses, diastolic FFR had comparable area under the curve (AUC) compared with FFR (AUC_{diastolic FFR}: 0.66; 95% confidence interval [CI]: 0.58-0.73, vs AUC_FFR: 0.66; 95% CI: 0.58-0.74, P = 0.624). FFR and diastolic FFR showed significantly larger AUCs than resting Pd/Pa (0.62; 95% CI: 0.54-0.70; P = 0.033 and P = 0.046) but did not show significantly larger AUCs than dPR (0.62; 95% CI: 0.55-0.70; P = 0.102 and P = 0.113).

Conclusions

Diastolic FFR showed a similar diagnostic performance to FFR as compared with MPS. This result reaffirms the use of FFR as the most accurate invasive physiological lesion assessment. (Diagnostic accuracy of diastolic fractional flow reserve (d-FFR) for functional evaluation of coronary stenosis; UMIN000015906)

The Effects of Using Imagery to Elicit an External Focus of Attention

Background: An external focus of attention has been shown to be superior to adopting an internal focus of attention in a variety of motor skills. Purpose: To examine the efficacy of directing attention externally toward an imagined object when performing the standing long jump. This form of practice was compared to a group of participants that practiced the same motor skill while directing their attention toward an object that was physically present in the practice environment. Method: All participants performed a series of standing long-jumps on a rubber mat. Participants were randomly assigned to either an external focus condition where they were instructed to jump as close as possible to a cone that was directly in front of them. Or they were assigned to an imagery condition in which they were instructed to jump toward an imagined cone. Following acquisition trials, a 24-hr retention and transfer test was completed by all participants. Results: Significant improvement was demonstrated by both groups during acquisition, retention and transfer phases compared to the baseline measure. However, no significant differences were observed between the two experimental conditions. Conclusion: The findings of this experiment demonstrate that attention directed externally toward a physical object and an imagined object has a similar effect.

Multiple Gastric Carcinomas Associated with Epstein-Barr Virus and Helicobacter pylori: A Thought-Provoking Case

BACKGROUND Epstein-Barr virus (EBV) and Helicobacter pylori (HP) infections are associated with gastric carcinoma (GC). We present a thought-provoking case of multiple GCs associated with EBV and HP infections. CASE REPORT HP infection was incidentally detected in an asymptomatic 60-year-old man. Upper endoscopy revealed gastric "kissing" ulcers. The lesions were located in the body of the stomach and measured 25 and 27 mm, respectively. They were diagnosed on pathology as moderately differentiated tubular adenocarcinoma. Imaging revealed no enlarged lymph nodes or distant metastatic lesions. Distal gastrectomy with lymphadenectomy was performed and surgical cure was obtained. The multiple GCs were categorized on pathology as infß ly0 v0 pT1b(SM)UL1N0M0H0P0CY0 pStage IA according to the Japanese classification and as T1bN0M0 Stage IA according to the tumor, node, metastasis classification. Pathological examination revealed remarkable lymphocytic infiltration into the stroma, as shown by in situ hybridization of EBV. These lymphocytic infiltrations were observed only at the sites of GC. In the immunohistochemical examination, in situ hybridization of EBV was positive for EBV-encoded small ribonucleic acid. The patient's postoperative course was uneventful. Hence, an unexpected relationship between EBV infection and multiple GCs was suggested by pathology. Quantitative determination of EBV DNA in peripheral blood was normal postoperatively. Adjuvant chemotherapy was not recommended. HP eradication therapy was successful. The patient remained asymptomatic and developed no recurrence or metastasis for 3 years after surgery. CONCLUSIONS This thought-provoking case suggests that coinfection with EBV and HP increases GC occurrence.