Prospective Observational Study for the Comparison of Screening Methods Including Tongue Pressure and Repetitive Saliva Swallowing With Detailed Videofluoroscopic Swallowing Study Findings in Patients With Acute Stroke

BACKGROUND

Simple, noninvasive, and repeatable screening methods are essential for assessing swallowing disorders. We focused on patients with acute stroke and aimed to assess the characteristics of swallowing screening tests, including the modified Mann Assessment of Swallowing Ability score, tongue pressure, and repetitive saliva swallowing test (RSST), compared with detailed videofluoroscopic swallowing study (VFSS) findings to contribute as a helpful resource for their comprehensive and complementary use.

METHODS AND RESULTS

We enrolled first-ever patients with acute stroke conducting simultaneous assessments, including VFSS, modified Mann Assessment of Swallowing Ability score, tongue pressure measurement, and RSST. VFSS assessed aspiration, laryngeal penetration, oral cavity residue, vallecular residue, pharyngeal residue, and swallowing reflex delay. Screening tests were compared with VFSS findings, and multiple logistic analysis determined variable importance. Cutoff values for each abnormal VFSS finding were assessed using receiver operating characteristic analyses. We evaluated 346 patients (70.5±12.6 years of age, 143 women). The modified Mann Assessment of Swallowing Ability score was significantly associated with all findings except aspiration. Tongue pressure was significantly associated with oral cavity and pharyngeal residue. The RSST was significantly associated with all findings except oral cavity residue. Receiver operating characteristic analyses revealed that the minimum cutoff value for all VFSS abnormal findings was RSST ≤2.

CONCLUSIONS

The modified Mann Assessment of Swallowing Ability is useful for broadly detecting swallowing disorders but may miss mild issues and aspiration. The RSST, with a score of ≤2, is valuable for indicating abnormal VFSS findings. Tongue pressure, especially in oral and pharyngeal residues, is useful. Combining these tests might enhance accuracy of the swallowing evaluation.

Association between Carotid Wall Shear Stress-Based Vascular Vector Flow Mapping and Cerebral Small Vessel Disease

AIM

Wall shear stress (WSS) is the frictional force caused by viscous blood flowing along the vessel wall. Decreased WSS is associated with local vascular endothelial dysfunction and atherosclerosis. The vector flow mapping (VFM) technique detects the direction of intracardiac blood flow and WSS on the vessel wall with echocardiography. In this study, we examined carotid WSS by applying the VFM technique to the carotid arteries and evaluated its relationship with cerebral small vessel disease (SVD).

METHODS

This is a single-center, prospective, observational study. We investigated the association between carotid WSS and SVD imaging, and cognitive outcomes in consecutive 113 patients with acute lacunar infarction.

RESULTS

Carotid WSS was negatively associated with age (r=-0.376, p＜0.001). Lower WSS was correlated with total SVD scores (ρ=-0.304, p=0.004), especially with enlarged perivascular space (EPVS) in the basal ganglia ＞10 (p＜0.001). The carotid intima-media thickness was not associated with the total SVD score (ρ=-0.183, p=0.052). Moreover, lower WSS was associated with executive dysfunction.

CONCLUSION

EPVS has recently been reported as a marker of early SVD imaging, and executive dysfunction is common in vascular cognitive impairment. These results suggested that decreased carotid WSS based on vascular VFM, which can be measured easily, is associated with imaging and cognitive changes in the early stages of SVD.

Usefulness of PETRA-MRA for Postoperative Follow-Up of Stent-Assisted Coil Embolization of Cerebral Aneurysms

Objective

Image evaluation after stent-assisted coil embolization (SAC) for a cerebral aneurysm is difficult with conventional MRA or CTA because of metal artifacts. Pointwise encoding time reduction with radial acquisition (PETRA)-MRA is a noninvasive imaging examination that can reduce metal artifacts. This study aimed to examine whether PETRA-MRA can be used as a follow-up imaging after SAC.

Methods

Twelve patients (eight women and four men; mean age, 66.9 ± 13.2 years) underwent SAC for unruptured aneurysms and were retrospectively evaluated using time-of-flight (TOF)- and PETRA-MRA data from the same follow-up session. Two neurosurgeons independently compared the aneurysm occlusion status and flow visualization score in the stented parent artery (4-point scale, where 4 points represented excellent visualization) between TOF- and PETRA-MRA images. If DSA was performed within 3 months before or after PETRA-MRA, the aneurysm assessment was compared between MRA and DSA. The interobserver agreement for each MRA was evaluated.

Results

Nine of the 12 patients underwent DSA within 3 months before and after TOF- and PETRA-MRA. The aneurysm occlusion status on DSA was more consistent with PETRA-MRA (eight of nine cases) than with TOF-MRA (one of nine cases; P = 0.023). The median visualization score of the stented parent artery was significantly higher for PETRA-MRA (4 [interquartile range {IQR} 3-4]) than for TOF-MRA (1 [IQR 1-1], P = 0.003). The interobserver agreement for evaluation of the aneurysm occlusion status and visualization score of the parent artery for PETRA-MRA were excellent (κ = 0.98 and 0.93, respectively). In one case, PETRA-MRA was able to detect aneurysm recurrence, leading to subsequent retreatment.

Conclusion

PETRA-MRA is a noninvasive examination that can be used to evaluate the occlusion status of aneurysms after SAC and visualize the stented parent artery. PETRA-MRA is useful for repeated follow-up examinations after SAC.

Comparison of risk factors for SARS-CoV-2 infection among healthcare workers during Omicron and Delta dominance periods in Japan

BACKGROUND

The risk factors for coronavirus disease (COVID-19) among healthcare workers (HCWs) might have changed since the emergence of the highly immune evasive Omicron variant.

AIM

To compare the risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among HCWs during the Delta- and Omicron-predominant periods.

METHODS

Using data from repeated serosurveys among the staff of a medical research centre in Tokyo, two cohorts were established: Delta period cohort (N = 858) and Omicron period cohort (N = 652). The potential risk factors were assessed using a questionnaire. Acute/current or past SARS-CoV-2 infection was identified by polymerase chain reaction or anti-nucleocapsid antibody tests, respectively. Poisson regression was used to calculate the risk ratio (RR) of infection risk.

FINDINGS

The risk of SARS-CoV-2 infection during the early Omicron-predominant period was 3.4-fold higher than during the Delta-predominant period. Neither working in a COVID-19-related department nor having a higher degree of occupational exposure to SARS-CoV-2 was associated with an increased infection risk during both periods. During the Omicron-predominant period, infection risk was higher among those who spent ≥30 min in closed spaces, crowded spaces, and close-contact settings without wearing mask (≥3 times versus never: RR: 6.62; 95% confidence interval: 3.01-14.58), whereas no such association was found during the Delta period.

CONCLUSION

Occupational exposure to COVID-19-related work was not associated with the risk of SARS-CoV-2 infection in the Delta or Omicron period, whereas high-risk behaviours were associated with an increased infection risk during the Omicron period.

Peak expiratory flow, but not tongue pressure, can predict pneumonia development in older adults

PURPOSE

Pneumonia is the leading cause of mortality and morbidity in aging populations. Major causes of pneumonia in older adults are swallowing dysfunction and decreased airway clearance capacity, including an impaired cough reflex. Maximal tongue pressure is useful for evaluating swallowing function, and peak expiratory flow indirectly reflects cough strength. However, it is unclear whether they can predict pneumonia development in older adults. In this study, we investigated whether tongue pressure and peak expiratory flow could predict pneumonia development in older adults.

METHODS

This two-center prospective observational study included older adults aged 65 years or older without respiratory disease or head and neck cancer. We enrolled 383 consenting participants, many of whom had a history of stroke, and followed them for 2 years. The association between time to pneumonia development and tongue pressure or peak expiratory flow at enrollment was examined in a Cox proportional hazards model.

RESULTS

The mean age of the participants was 77.1 ± 6.2 years, and 36.0% of them were women. The mean tongue pressure was 35.4 ± 10.5 kPa and median peak expiratory flow was 218 L/min at enrollment. Six patients developed pneumonia during the study period. A low peak expiratory flow at enrollment was significantly associated with pneumonia development in the multivariate Cox proportional hazards model, but this association was not observed for tongue pressure.

CONCLUSION

Decreased peak expiratory flow may predict pneumonia development in older adults. Future studies should investigate interventions for peak expiratory flow improvement.

Association of ankle-brachial index with cognitive decline in patients with lacunar infarction

Atherosclerosis is an important risk factor for cognitive decline. This study aimed to investigate the relationship of ankle-brachial pressure index (ABI) and brachial-ankle pulse wave velocity (baPWV) with cognitive function in patients with lacunar infarction. We included records of consecutive patients with their first-ever acute stroke and a diagnosis of lacunar infarction through magnetic resonance imaging (MRI) from July 1, 2011 to December 31, 2018. We excluded patients diagnosed with dementia, including strategic single-infarct dementia, before or after stroke onset. Moreover, we excluded patients with one or more microbleeds, severe white matter lesions, or severe medial temporal atrophy on MRI. For ABI, we used the lower ankle side and divided the results into ABI < 1.0 and ABI ≥ 1.0. For baPWV, we used the higher ankle side and divided the results into two groups based on the median value of the participants. We analyzed 176 patients with stroke (age 72.5 ± 11.4 years, 67 females). The median score on the Mini-Mental State Examination (MMSE) was 27. The number of patients with ABI < 1.0 was 19 (10.8%). Univariate analysis revealed that the MMSE score was associated with age, body mass index, education, chronic kidney disease, periventricular hyperintensity, and ABI < 1.0 (p < 0.10), but not baPWV. Multivariate analysis revealed that body mass index (p = 0.039) and ABI < 1.0 (p = 0.015) were independently associated with the MMSE score. For patients with lacunar infarction, a lower ABI, but not a higher PWV, was associated with cognitive decline.

Effect of region-wide use of prehospital stroke triage scale on management of patients with acute stroke

BACKGROUND

Prehospital stroke triage scales help with the decision to transport patients with suspected stroke to suitable hospitals.

OBJECTIVE

To explore the effect of the region-wide use of the Japan Urgent Stroke Triage (JUST) score, which can predict several types of stroke: large vessel occlusion (LVO), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), and cerebral infarction other than LVO (CI).

METHODS

We implemented the JUST score and conducted a retrospective and prospective multicenter cohort study at 13 centers in Hiroshima from April 1, 2018, to March 31, 2020. We investigated the success rate of the first request to the hospital, on-scene time, and transport time to hospital. We evaluated the door-to-puncture time, puncture-to-reperfusion time, and 90-day outcome among patients with final diagnoses of LVO.

RESULTS

The cohort included 5141 patients (2735 before and 2406 after JUST score implementation). Before JUST score implementation, 1269 strokes (46.4%) occurred, including 140 LVO (5.1%), 394 ICH (14.4%), 120 SAH (4.4%), and 615 CI (22.5%). The JUST score was used in 1484 (61.7%) of the 2406 patients after implementation, which included 1267 (52.7%) cases of stroke (186 LVO (7.7%), 405 ICH (16.8%), 109 SAH (4.5%), and 567 CI (23.6%)). Success rate of the first request to the hospital significantly increased after JUST score implementation (76.3% vs 79.7%, p=0.004). JUST score implementation significantly shortened the door-to-puncture time (84 vs 73 min, p=0.03), but the prognosis remained unaltered among patients with acute LVO.

CONCLUSIONS

Use of prehospital stroke triage scales improved prehospital management and preparation time of intervention among patients with acute stroke.

Relationship between tongue pressure and dysphagia diet in patients with acute stroke

A dysphagia diet is important for patients with stroke to help manage their nutritional state and prevent aspiration pneumonia. Tongue pressure measurement is a simple, non-invasive, and objective method for diagnosing dysphagia. We hypothesized that tongue pressure may be useful in making a choice of diet for patients with acute stroke. Using balloon-type equipment, tongue pressure was measured in 80 patients with acute stroke. On admission, a multidisciplinary swallowing team including doctors, nurses, speech therapists, and management dietitians evaluated and decided on the possibility of oral intake and diet form; the tongue pressure was unknown to the team. Diet form was defined and classified as dysphagia diet Codes 0 to 4 and normal form (Code 5 in this study) according to the 2013 Japanese Dysphagia Diet Criteria. In multivariate analysis, only tongue pressure was significantly associated with the dysphagia diet form (p<0.001). Receiver operating characteristic analyses revealed that the optimal cutoff tongue pressure for predicting diet Codes 1, 2, 3, 4, and 5 was 3.6 (p<0.001, area under the curve [AUC] = 0.997), 9.6 (p<0.001, AUC = 0.973), 12.8 (p<0.001, AUC = 0.963), 16.5 (p<0.001, AUC = 0.979), and 17.3 kPa (p<0.001, AUC = 0.982), respectively. Tongue pressure is one of the sensitive indicators for choosing dysphagia diet forms in patients with acute stroke. A combination of simple modalities will increase the accuracy of the swallowing assessment and choice of the diet form.

Low-dose Contrast-induced Encephalopathy During Diagnostic Cerebral Angiography

Contrast-induced encephalopathy (CIE) is a rare complication of contrast agent use. We herein report a case of acute lacunar infarction in a 70-year-old woman. During diagnostic cerebral angiography for asymptomatic common carotid stenosis, she experienced transient drowsiness. After angiography, generalized tonic-clonic seizures occurred in her left arm and leg, with eye deviation to the left. The patient was diagnosed with CIE due to the acute onset of symptoms during angiography and characteristic computed tomography findings of high-density signaling in the cortex. Our findings suggest that it is important to pay close attention to acute neurological symptoms during and immediately after examinations, even with small amounts of contrast agents.

Patient Health Questionnaire-9 predicts the functional outcome of stroke patients in convalescent rehabilitation ward

INTRODUCTION

Poststroke depression (PSD) negatively affects the functional outcome of stroke patients. Patient Health Questionnaire-9 (PHQ-9) is a validated screening tool for detecting PSD. This study investigated the relationship between PHQ-9 score and functional outcomes in stroke patients in a convalescent rehabilitation ward by evaluating functional independence measure (FIM) gain scores and the proportion of patients discharged.

METHODS

In this retrospective study conducted from January 2017 to September 2019, consecutive stroke patients who were admitted to the convalescent rehabilitation ward and could answer PHQ-9 were assessed. The association between PHQ-9 scores at the time of admission to the convalescent rehabilitation ward and outcomes (FIM gain score and the proportion of patients discharged) was statistically analyzed.

RESULTS

Among the 215 patients enrolled in the study, 62 (28.8%) were assessed as having depression, in whom PHQ-9 scores were 5 or above. Multivariate analysis revealed that the PHQ-9 score on admission to the convalescent rehabilitation ward was a significant independent factor influencing the FIM gain score (p = .009). In addition, a multivariate analysis revealed that the PHQ-9 score at the time of admission to the convalescent rehabilitation ward was a significant independent factor influencing the inability to discharge a patient (odds ratio 1.24, 95% confidence interval 1.12-1.39, p < .001).

CONCLUSIONS

The PHQ-9 score is a useful tool for predicting patient functional outcome, admission to the facility, and screening for poststroke depression.

Simplified cough test can predict the risk for pneumonia in patients with acute stroke

We investigated the association between the results of a simplified cough test and pneumonia onset in 226 patients with acute stroke admitted to Suiseikai Kajikawa Hospital from April to December, 2018. For the simplified cough test, performed on admission, patients orally inhaled a mist of 1% citric acid–physiological saline using a portable mesh nebulizer. When the first cough was evoked or if it remained absent for 30 seconds (indicating an abnormal result), the test was ended. Patients also completed the repetitive saliva swallowing test (RSST) and modified water swallowing test. We monitored patients for pneumonia signs for 30 days post-admission. Eighteen patients exhibited an abnormal simplified cough test result. On multivariate analysis, an abnormal RSST result was independently associated with an abnormal simplified cough test result. Seventeen patients developed pneumonia. The adjusted Cox proportional hazard model for pneumonia onset revealed that the simplified cough test had predictive power for pneumonia onset (hazard ratio, 10.52; 95% confidence interval, 3.72–29.72). The simplified cough test is a strong indicator for predicting the pneumonia development in patients with acute stroke; it should be added to existing bedside screening tests for predicting pneumonia risk, allowing appropriate and timely intervention.

Tongue thickness measured by ultrasonography is associated with tongue pressure in the Japanese elderly

The term "oral frailty" reflects the fact that oral health is associated with physical frailty and mortality. The gold standard methods for evaluating the swallowing function have several problems, including the need for specialized equipment, the risk of radiation exposure and aspiration, and general physicians not possessing the requisite training to perform the examination. Hence, several simple and non-invasive techniques have been developed for evaluating swallowing function, such as those for measuring tongue pressure and tongue thickness. The aim of this study was to investigate the relationship between tongue thickness ultrasonography and tongue pressure in the Japanese elderly. We evaluated 254 elderly patients, who underwent tongue ultrasonography and tongue pressure measurement. To determine tongue thickness, we measured the vertical distance from the surface of the mylohyoid muscle to the tongue dorsum using ultrasonography. The results of the analyses revealed that tongue thickness was linearly associated with tongue pressure in both sexes. In male participants, dyslipidemia, lower leg circumference, and tongue pressure were independently and significantly associated with tongue thickness. In female participants, body mass index and tongue pressure were independently and significantly associated with tongue thickness. The optimal cutoff for tongue thickness to predict the tongue pressure of < 20 kPa was 41.3 mm in males, and 39.3 mm in females. In the Japanese elderly, tongue thickness using ultrasonography is associated with tongue pressure. Tongue thickness and tongue pressure, which are sensitive markers for oral frailty, decrease with age. We conclude that tongue ultrasonography provides a less invasive technique for determining tongue thickness and predicts oral frailty for elderly patients.

Magnetic resonance vessel wall imaging predicts morphological deterioration in unruptured intracranial artery dissection

OBJECTIVE

The mechanism involved in progression of unruptured intracranial artery dissection (IAD) is poorly understood. We investigated the relationship between contrast enhancement of dissecting lesions on magnetic resonance vessel wall imaging (MR-VWI) and unruptured IAD progression on the hypothesis that this finding might predict its instability.

METHODS

A total of 49 unruptured IADs were investigated retrospectively. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after injection of contrast medium, and the dissecting lesion/pituitary stalk contrast enhancement ratio (CR_stalk) was calculated. Unruptured IAD progression was defined as morphological deterioration; progressive dilatation or stenosis. The relations between unruptured IAD progression and potential risk factors were statistically investigated.

RESULTS

Morphological deterioration was demonstrated in eleven of 49 unruptured IADs (22 %). The CR_stalk value and male predominance was significantly higher in progressed IADs than stable ones (1.0 vs. 0.65; p = 0.0035, 82% vs 37%; p= 0.015, respectively). On stepwise multivariable logistic regression analysis, the CR_stalk value was independently associated with unruptured IAD progression with odds ratio of 102.5 (95% CI, 2.59-4059, P=0.0013). The optimal cutoff value of CR_stalk to estimate IADs with progression was 0.87 (sensitivity, 0.82; specificity, 0.74). Multimodalic images showed contrast enhancement on VWI corresponded to residual stagnant flow in dissecting lesions.

CONCLUSIONS

Quantitative analysis of contrast enhancement on VWI could predict instability of unruptured IADs. Contrast enhancement in dissecting lesions would be a clue to understand the mechanism of unruptured IAD progression.

The right hemisphere is important for driving-related cognitive function after stroke

Considering quality of life (QOL) after stroke, car driving is one of the most important abilities for returning to the community. In this study, directed attention and sustained attention, which are thought to be crucial for driving, were examined. Identification of specific brain structure abnormalities associated with post-stroke cognitive dysfunction related to driving ability would help in determining fitness for car driving after stroke. Magnetic resonance imaging was performed in 57 post-stroke patients (51 men; mean age, 63 ± 11 years) who were assessed for attention deficit using a standardized test (the Clinical Assessment for Attention, CAT), which includes a Continuous Performance Test (CPT)-simple version (CPT-SRT), the Behavioral Inattention Test (BIT), and a driving simulator (handle task for dividing attention, and simple and selective reaction times for sustained attention). A statistical non-parametric map (SnPM) that displayed the association between lesion location and cognitive function for car driving was created. From the SnPM analysis, the overlay plots were localized to the right hemisphere during handling the hit task for bilateral sides (left hemisphere damage related to right-side neglect and right hemisphere damage related to left-side neglect) and during simple and selective reaction times (false recognition was related to damage of both hemispheres). A stepwise multiple linear regression analysis confirmed the importance of both hemispheres, especially the right hemisphere, for cognitive function and car driving ability. The present study demonstrated that the right hemisphere has a crucial role for maintaining directed attention and sustained attention, which maintain car driving ability, improving QOL for stroke survivors.

Abstract TP86: Clinical Significance of Gadolinium Enhancement in Non-Hemorrhagic Intracranial Artery Dissection

Background and Purpose: The mechanisms involved in progression of non-hemorrhagic intracranial artery dissection (IAD) are poorly understood. Contrast enhancement of intracranial saccular aneurysms on magnetic resonance vessel wall imaging (VWI) is thought to predict instability. We investigated the relationship between contrast enhancement of dissecting lesions and progression of IADs based on the hypothesis that this finding might predict instability.

Methods: A total of 39 IADs in 36 patients (17 women and 19 men; mean age: 49 years) were investigated retrospectively. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after injection of contrast medium, and the vessel wall/pituitary stalk contrast enhancement ratio (CRstalk) was calculated. Progression of IADs was defined as morphological deterioration; progressive dilatation or stenosis. The relations between IAD progression and potential risk factors, including patient demographic data, IAD morphology, and VWI findings, were investigated by statistical analysis.

Results: The mean follow-up period was 9.7 months (range: 1-24 months). Progression was detected in 6 of 39 IADs (15%). Five IADs demonstrated aneurysmal dilatation and the other showed stenosis/occlusion. There were no significant differences of demographic factors between the patients with or without IADs progression. IADs with aneurysmal dilation demonstrated significant morphological deterioration (p=0.01). All IADs without contrast enhancement (n=7) improved within one month. Contrast enhancement corresponded to the pseudo-lumen of dissecting lesions. The CRstalk value was significantly higher in IADs with progression than in stable lesions (1.10 ± 0.09 vs. 0.80 ± 0.05, p =0.01).

Conclusions: The pseudo-lumen of dissecting lesions may be identified by contrast enhancement. Quantitative analysis of contrast enhancement could be useful for predicting instability of IADs during follow-up.

Abstract WMP34: Multimodal Evaluation of Unruptured Intracranial Aneurysm Wall

Background and Purpose: Recent studies have suggested that MR-vessel wall imaging (VWI) or computational fluid dynamics (CFD) could evaluate aneurysm wall features in unruptured intracranial aneurysms (UIAs). The combination of these modalities might be comprehensive and help better understanding of the pathophysiology of aneurysm wall. This study was performed to disclose the relationship between VWI and hemodynamic characteristics evaluated by CFD.

Methods: From April 2017 through May 2019, a total of 36 microsurgically-treated UIAs preoperatively underwent VWI and CFD were reviewed. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after injection of contrast medium, and aneurysm wall enhancement (AWE) was evaluated. CFD was carried out using patient specific geometry models from three-dimensional CT angiography. Morphological variables, intraoperative inspection and hemodynamic parameters were statistically analyzed between enhanced and nonenhanced wall of UIAs. Fourteen UIAs were available for histopathological examination.

Results: In morphological variables, maximum diameter and irregularity were associated with AWE (p=0.02, respectively). AWE lesions corresponded to intraoperatively inspected atherosclerotic lesions of UIAs (sensitivity, 0.90; specificity, 0.79). Among hemodynamic parameters, oscillatory velocity index that suggests the directional changes of the flow velocity was significantly higher in UIAs with AWE (p=0.02). Histopathologic studies revealed that wall thickening accompanied by atherosclerosis, neovascularization, and macrophage infiltration corresponded to AWE lesions, while UIAs without AWE demonstrated various histopathological findings such as myointimal hyperplasia or thinning wall with loss of mural cells and wall degeneration.

Conclusions: Pathophysiology of AWE could be explained as atherosclerotic changes with inflammation presumably associated with aberrant flow conditions in irregular UIAs. VWI and CFD are complementarily valuable imaging techniques to understand an aneurysm wall pathophysiology.

Vessel Wall Imaging Predicts the Presence of Atherosclerotic Lesions in Unruptured Intracranial Aneurysms

BACKGROUND

Recent studies have suggested that magnetic resonance vessel wall imaging (VWI) can visualize thickened intracranial aneurysm wall. We aimed to investigate correlations between VWI findings and intraoperative aneurysm wall features based on the hypothesis that VWI can visualize atherosclerotic changes in unruptured intracranial aneurysm (UIA) walls.

METHODS

A total of 36 microsurgically treated UIAs were retrospectively reviewed. All aneurysms underwent VWI before microsurgical clipping, and fusion images with time-of-flight magnetic resonance angiography were created to localize aneurysm wall enhancement (AWE) lesions. Intraoperatively, 2 neurosurgeons who were blinded to the VWI findings evaluated the aneurysm wall features, giving each aneurysm an atherosclerosis score on a 5-point scale (5: yellowish, 4: whitish, 3: normal, 2: slightly reddish, 1: reddish). We defined atherosclerotic lesions as those having average scores ≥4. We evaluated the rate of correspondence between AWE lesions and atherosclerotic lesions, and the factors associated with AWE.

RESULTS

Sixteen of the 36 UIAs (44%) were identified as AWE. The sensitivity, specificity, positive predictive value, and negative predictive value of correspondence between AWE lesions and atherosclerotic lesions were 79%, 94%, 94%, and 80%, respectively. The average atherosclerosis scores (4.2 ± 0.5 vs. 2.7 ± 0.9; P < 0.001) were significantly higher in aneurysms with AWE. Twelve of 16 UIAs with wall enhancement had wall thinning adjacent to the part with AWE.

CONCLUSIONS

AWE lesions corresponded with intraoperatively confirmed atherosclerotic lesions of UIAs. Detecting these lesions would be valuable in exploring UIAs with wall degeneration.

Vessel Wall Imaging of Evolving Unruptured Intracranial Aneurysms

Background and Purpose- Unruptured intracranial aneurysms (UIAs) have various scenarios of growth and rupture. Magnetic resonance vessel wall imaging can detect aneurysmal wall thickening with inflammation and neovascularization. This study was performed to explore the vessel wall imaging findings of UIAs with consecutive follow-up. Methods- A total of 60 aneurysms with serial angiography over 2 years (mean period, 49 months, range, 24-192 months) were evaluated by vessel wall imaging. UIAs were morphologically categorized into 3 patterns: stable, whole sac expansion, or daughter sac formation. Aneurysm wall enhancement (AWE) was evaluated after administration of gadolinium. Results- Thirty-three of the 60 UIAs (55%) demonstrated no morphological changes, whereas 16 UIAS (27%) showed whole sac expansion and 11 UIAs (18%) demonstrated daughter sac formation. AWE was significantly less frequent in stable UIAs compared with UIAs showing morphological changes ( P<0.01). Aneurysms with daughter sac formation showed a significantly higher frequency of AWE than those demonstrating whole sac expansion. In the majority of UIAs with daughter sac formation, AWE was detected in the main aneurysm and not in the developing component. Conclusions- UIAs demonstrate various modes of growth. The pattern of AWE might be useful for identifying unfavorable morphological changes of UIAs.

Cigarette smoking and cervical cancer risk: an evaluation based on a systematic review and meta-analysis among Japanese women

Background

There is a body of evidence to suggest that cigarette smoking increases the risk of cervical cancer in women, but no study has examined the magnitude of the association in Japanese women. Here, we evaluated the association between cigarette smoking and the risk of cervical cancer in Japanese women based on a systematic review of epidemiological evidence.

Methods

Original data were obtained from a MEDLINE search using PubMed or from a search of the 'Ichushi' database, as well as by a manual search. Evaluation of associations was based on the strength of evidence and the magnitude of association, together with biological plausibility as evaluated previously by the International Agency for Research on Cancer. Meta-analysis of associations was also conducted to obtain a summarized overview of the data.

Results

We identified two cohort studies and three case-control studies. All five studies had indicated strong positive associations between cigarette smoking and the risk of cervical cancer. Our summary estimate indicated that the relative risk (RR) for individuals who had ever-smoked relative to never-smokers was 2.03 (95% confidence interval: 1.49-2.57). Four studies had also demonstrated dose-response relationships between cigarette smoking and the risk of cervical cancer.

Conclusion

We conclude that there is convincing evidence that cigarette smoking increases the risk of cervical cancer among Japanese women.

Evidence-based cancer prevention recommendations for Japanese

A comprehensive evidence-based cancer prevention recommendation for Japanese was developed. We evaluated the magnitude of the associations of lifestyle factors and infection with cancer through a systematic review of the literature, meta-analysis of published data, and pooled analysis of cohort studies in Japan. Then, we judged the strength of evidence based on the consistency of the associations between exposure and cancer and biological plausibility. Important factors were extracted and summarized as an evidence-based, current cancer prevention recommendation: 'Cancer Prevention Recommendation for Japanese'. The recommendation addresses six important domains related to exposure and cancer, including smoking, alcohol drinking, diet, physical activity, body weight and infection. The next step should focus on the development of effective behavior modification programs and their implementation and dissemination.

Predictive performance of a genetic risk score using 11 susceptibility alleles for the incidence of Type 2 diabetes in a general Japanese population: a nested case-control study

AIMS

To assess the predictive ability of a genetic risk score for the incidence of Type 2 diabetes in a general Japanese population.

METHODS

This prospective case-control study, nested within a Japan Public Health Centre-based prospective study, included 466 participants with incident Type 2 diabetes over a 5-year period (cases) and 1361 control participants, as well as 1463 participants with existing diabetes and 1463 control participants. Eleven susceptibility single nucleotide polymorphisms, identified through genome-wide association studies and replicated in Japanese populations, were analysed.

RESULTS

Most single nucleotide polymorphism loci showed directionally consistent associations with diabetes. From the combined samples, one single nucleotide polymorphism (rs2206734 at CDKAL1) reached a genome-wide significance level (odds ratio 1.28, 95% CI 1.18-1.40; P = 1.8 × 10^-8 ). Three single nucleotide polymorphisms (rs2206734 in CDKAL1, rs2383208 in CDKN2A/B, and rs2237892 in KCNQ1) were nominally significantly associated with incident diabetes. Compared with the lowest quintile of the total number of risk alleles, the highest quintile had a higher odds of incident diabetes (odds ratio 2.34, 95% CI 1.59-3.46) after adjusting for conventional risk factors such as age, sex and BMI. The addition to the conventional risk factor-based model of a genetic risk score using the 11 single nucleotide polymorphisms significantly improved predictive performance; the c-statistic increased by 0.021, net reclassification improved by 6.2%, and integrated discrimination improved by 0.003.

CONCLUSIONS

Our prospective findings suggest that the addition of a genetic risk score may provide modest but significant incremental predictive performance beyond that of the conventional risk factor-based model without biochemical markers.

Dietary patterns and type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study

BACKGROUND/OBJECTIVE

Dietary patterns in Western populations have been linked to type 2 diabetes, but the association of distinctive dietary patterns of Japanese population remains unclear. We prospectively investigated the association between dietary patterns and risk of developing type 2 diabetes among Japanese adults.

SUBJECTS/METHODS

Participants were 27, 816 men and 36,889 women aged 45-74 years who participated in the second survey of the Japan Public Health Center-based prospective study and had no history of diabetes. Dietary patterns were derived by using principal component analysis of the consumption of 134 food and beverage items ascertained by a food frequency questionnaire. Odds ratios of self-reported physician-diagnosed type 2 diabetes over 5 year were estimated using logistic regression analysis.

RESULTS

A total of 1194 new cases (692 men and 502 women) of type 2 diabetes were self-reported. We identified three dietary patterns: prudent, westernized and traditional Japanese patterns. Any dietary pattern was not significantly associated with type 2 diabetes risk after adjustment for covariates in both men and women. The multivariate-adjusted odds ratios (95% confidence interval) for type 2 diabetes for the highest versus lowest quartile of each dietary pattern score in men and women, respectively, were 0.93 (0.74-1.16) and 0.90 (0.69-1.16) for the prudent pattern, 1.15 (0.90-1.46) and 0.81 (0.61-1.08) for the westernized pattern, and 0.97 (0.74-1.27) and 0.87 (0.66-1.15) for the traditional pattern.

CONCLUSIONS

Although a small protective effect of the prudent dietary pattern cannot be excluded, dietary patterns may not be appreciably associated with type 2 diabetes risk in Japanese.

Serum 25-hydroxyvitamin D and markers of insulin resistance in a Japanese working population

BACKGROUND/OBJECTIVES

The association between vitamin D status and insulin resistance (IR) has been less studied among Asians, and it remains elusive whether calcium could modify such an association. We examined the association of serum 25-hydroxyvitamin D (25(OH)D) concentrations with IR markers and the potential effect modification by calcium intake among a Japanese population.

SUBJECTS/METHODS

The authors analyzed data (n=494) from a cross-sectional survey conducted in 2009 among a Japanese working population aged 20-68 years. Fasting serum 25(OH)D and insulin, as well as fasting plasma glucose were determined, and homeostatic model assessment of IR (HOMA-IR) was calculated. Calcium intake was assessed using a validated diet history questionnaire. Multiple linear regression was done with adjustment of potential confounding variables.

RESULTS

Fasting insulin and HOMA-IR were significantly inversely associated with 25(OH)D concentration across quartiles of 25(OH)D after fully adjusting for covariates (P(trend)=0.04 and 0.02, respectively). Across clinically relevant categories of 25(OH)D, compared with participants in the vitamin D sufficiency group, those in the vitamin D insufficiency group had a 5% higher HOMA-IR score, and those in the hypovitaminosis D group had an 18% higher HOMA-IR score (P(trend)=0.01). In an analysis by calcium intake, the HOMA-IR score was highest among participants with both a low calcium intake and lowest 25(OH)D concentrations, with significant inverse trend being observed in the group with lower calcium intake (P(trend)=0.02).

CONCLUSIONS

Our findings suggest that low vitamin D status is associated with IR among Japanese adults.

Visceral fat area cutoff for the detection of multiple risk factors of metabolic syndrome in Japanese: the Hitachi Health Study

The relationships between metabolic risk factors and abdominal fat distribution determined using computed tomography (CT) are poorly defined in large populations. We investigated the cutoff values of the visceral fat area (VFA) to detect subjects with multiple risk factors of metabolic syndrome (MS) by sex and age groups, and attempted to examine whether sex- and age-specific cutoff values are needed. The subjects of this study were 11,561 Japanese men and women who participated in the Hitachi Health Study, received CT examination, and answered questionnaires on lifestyles between 2004 and 2009. VFA and waist circumference were measured using CT. The VFA cutoff values yielding an 80% sensitivity for the detection of multiple risk factors of MS were typically smaller among men under the age of 40 years (<40 years vs. ≥40 years; 86.4 cm(2) vs. 103.9 cm(2)). The area under the receiver operator characteristic curve of VFA for the detection tended to decrease according to age (P = 0.056 and P = 0.020 for trends in men and women). Age- and sex-specific cutoff values are needed. The sensitivity of the subjects under the age of 40 years is relatively smaller (70.0% for men and 60.0% for women) compare to other age groups when the same cutoff value is used regardless of age (e.g., cutoff value calculated to correspond to 80% sensitivity for subjects of all ages). Therefore, a smaller VFA cutoff point should be used among men under the age of 40 years.

Short sleep duration in association with CT-scanned abdominal fat areas: the Hitachi Health Study

OBJECTIVE

To examine the relationship between short sleep duration and body mass index (BMI), waist circumference (WC), visceral fat area (VFA) and subcutaneous fat area (SFA) among a working population in Japan.

DESIGN

Health-center-based, cross-sectional study.

SUBJECTS

The study subjects included 5400 men and 642 women aged 30 to 75 years who underwent an abdominal computed tomography (CT) scanning examination in a comprehensive health checkup.

MEASUREMENTS

Height and weight were measured, and BMI was calculated. WC, VFA and SFA were measured using a CT scanner. Sleep duration was self-reported. Analysis of covariance was used to estimate adjusted means of BMI, WC, VFA and SFA across categories of sleep duration with adjustments for potential confounders. Trend of the association was assessed using multiple linear regression analysis.

RESULTS

In men, the mean values of BMI, WC and SFA decreased with increasing sleep duration after adjustment for age, physical activity, smoking and drinking (P-value for trend <0.001). Additional adjustment for physical illnesses did not attenuate the explanatory power of the models (P-value for trend <0.001). In addition, the association between sleep duration and SFA did not change after controlling for VFA (P-value for trend <0.001). The mean values of SFA for subjects sleeping '<5 h', '5 to <6 h', '6 to <7 h' and '7 h' per day were 145.8±67.4 cm(2), 138.7±61.5 cm(2), 134.7±60.4 cm(2) and 132.5±49.2 cm(2), respectively. Sleep duration was not appreciably associated with VFA. In women, no significant association was detected in any models.

CONCLUSION

Shorter sleep duration is associated with higher BMI, WC and SFA in men. Further research is needed to explicate the biological mechanisms behind these relationships and to see whether interventions addressing inadequate sleep could treat or prevent obesity by taking gender differences into consideration.

Association between body mass index and the colorectal cancer risk in Japan: pooled analysis of population-based cohort studies in Japan

BACKGROUND

Obesity has been recognized as important risk factors for colorectal cancer. However, limited evidence is available on colorectal cancer and body mass index (BMI) in Asian population.

METHODS

We conducted a pooled analysis of eight population-based prospective cohorts studies in Japan with more than 300,000 subjects to evaluate an impact of obesity in terms of BMI on colorectal cancer risk with unified categories. We estimated summary hazard ratio (HR) by pooling of study-specific HR for BMI categories with random effect model.

RESULTS

We found a significant positive association between BMI and colorectal cancer risk in male and female. Adjusted HRs for 1 kg/m(2) increase were 1.03 [95% confidence interval (CI) 1.02-1.04] for males and 1.02 (95% CI 1.00-1.03) for females. The association was stronger in colon, especially in proximal colon, relative to rectum. Males showed a stronger association than females. Population attributable fraction for colorectal cancer by BMI ≥ 25 kg/m(2) was 3.62% (95% CI 1.91-5.30) for males and 2.62% (95% CI 0.74-4.47) for females.

CONCLUSIONS

We found significant association between BMI and colorectal cancer risk by pooling of data from cohort studies with considerable number of subjects among Japanese population. This information is important in cancer control planning, especially in Asian population.

Prognostic significance of expression patterns of EGFR family, p21 and p27 in high-grade astrocytoma

The goal of this study was to investigate the relationship among immunohistochemical expression of epithelial growth factor receptor (EGFR) family proteins, p21, p27 and prognosis in patients with high-grade astrocytoma. Expression of EGFR family proteins (c-erbB-1, c-erbB-2, c-erbB-3, c-erbB-4), p21 and p27 and Ki-67 labeling index (LI) were studied in 59 samples of high-grade astrocytoma. Expression of protein levels was analyzed by immunohistochemical staining of formalin-fixed and paraffin-embedded sections. Results were analyzed in relation to age, gender and survival. Overexpression of c-erbB-1, c-erbB-2, c-erbB-3 and c-erbB-4 was found in 40 (67.8%), 17 (28.8%), 3 (5.1%) and 42 (75.0%) samples, respectively. Similarly, low expression of p21 and p27 was observed in 50 (84.8%) and 27 (45.8%) samples. Mean Ki-67 LI was 17.3 +/- 1.1. Cox multiple regression analysis showed that c-erbB-1 (Hazard rate(HR) 1.57, 95% Confidence interval (CI) 1.08-2.36; p = 0.017), c-erbB-4 (HR 1.79, 95% CI 1.20-2.74; p = 0.004) and p27 (HR 0.50, 95% CI 0.30-0.82; p = 0.006) were significantly associated with survival. High expression of c-erbB-1 and c-erbB-4 and low expression of p27 were associated with poor prognosis in these patients.

Serum folate and homocysteine and depressive symptoms among Japanese men and women

BACKGROUND/OBJECTIVES

Folate and homocysteine have been implicated to have a role in depression. However, results of epidemiologic studies on this issue have been inconsistent. The objective of this study was to clarify the association between serum folate and homocysteine concentrations and depressive symptoms in Japanese adults.

SUBJECTS/METHODS

We analyzed cross-sectional data for 530 municipal employees (313 men and 217 women), aged 21-67 years, who participated in a health survey at the time of periodic checkup. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Logistic regression analysis was used to estimate odds ratios of depressive symptoms (CES-D scale scores of >or=16) with adjustment for potential confounding variables.

RESULTS

In total, 113 men (36.1%) and 79 women (36.4%) had depressive symptoms. A higher serum folate was associated with a decreased prevalence of depressive symptoms in men. The multivariate-adjusted odds ratios (95% confidence interval) of depressive symptoms for the lowest to highest quartiles of serum folate were 1.00 (reference), 0.53 (0.27-1.03), 0.33 (0.16-0.68) and 0.51 (0.25-1.03), respectively (trend P=0.03). Furthermore, the data suggested a positive association between serum homocysteine and depressive symptoms in men (trend P=0.06). In women, neither folate nor homocysteine was associated with depressive symptoms.

CONCLUSIONS

Low serum folate may be related to an increased prevalence of depressive symptoms in Japanese men.

Calcium, vitamin D and dairy intake in relation to type 2 diabetes risk in a Japanese cohort

AIMS/HYPOTHESIS

Calcium and vitamin D have been implicated in the development of type 2 diabetes, but epidemiological evidence is limited. We examined prospectively the relation of calcium and vitamin D intake to type 2 diabetes risk in a Japanese cohort.

METHODS

Participants were 59,796 middle-aged and older men and women, who participated in the Japan Public Health Center-based Prospective Study and had no history of type 2 diabetes or other serious diseases. Dietary intake of calcium and vitamin D were estimated using a validated food frequency questionnaire. Logistic regression was used to assess the association between intake of these nutrients and self-reported newly diagnosed type 2 diabetes.

RESULTS

During a 5 year follow-up, 1,114 cases of type 2 diabetes were documented. Overall, calcium intake was not associated with a significantly lower risk of type 2 diabetes; the multivariable odds ratio for the highest vs lowest quartiles was 0.93 (95% CI 0.71-1.22) in men and 0.76 (95% CI 0.56-1.03) in women. However, among participants with a higher vitamin D intake, calcium intake was inversely associated with diabetes risk; the odds ratio for the highest vs lowest intake categories was 0.62 (95% CI 0.41-0.94) in men and 0.59 (95% CI 0.38-0.91) in women. Dairy food intake was significantly associated with a lower risk of type 2 diabetes in women only.

CONCLUSIONS/INTERPRETATION

Calcium and vitamin D may not be independently associated with type 2 diabetes risk. Our finding suggesting a joint action of these nutrients against type 2 diabetes warrants further investigation.

Green tea consumption and gastric cancer in Japanese: a pooled analysis of six cohort studies

BACKGROUND

Previous experimental studies have suggested many possible anti-cancer mechanisms for green tea, but epidemiological evidence for the effect of green tea consumption on gastric cancer risk is conflicting.

OBJECTIVE

To examine the association between green tea consumption and gastric cancer.

METHODS

We analysed original data from six cohort studies that measured green tea consumption using validated questionnaires at baseline. Hazard ratios (HRs) in the individual studies were calculated, with adjustment for a common set of variables, and combined using a random-effects model.

RESULTS

During 2 285 968 person-years of follow-up for a total of 219 080 subjects, 3577 cases of gastric cancer were identified. Compared with those drinking <1 cup/day, no significant risk reduction for gastric cancer was observed with increased green tea consumption in men, even in stratified analyses by smoking status and subsite. In women, however, a significantly decreased risk was observed for those with consumption of > or =5 cups/day (multivariate-adjusted pooled HR = 0.79, 95% confidence interval (CI) = 0.65 to 0.96). This decrease was also significant for the distal subsite (HR = 0.70, 95% CI = 0.50 to 0.96). In contrast, a lack of association for proximal gastric cancer was consistently seen in both men and women.

CONCLUSIONS

Green tea may decrease the risk of distal gastric cancer in women.