Short-latency reaction time and accuracy are impaired in patients with cirrhosis: An international multicenter retrospective study

AIM

The inability to quickly react to an external event can lead to an increased risk for accidents (e.g., falls, car crashes) in patients with cirrhosis. The aim of this study was to determine whether a novel clinically feasible measure of simple reaction time (SRT) and reaction accuracy (RA)-a go/no-go task occurring within 400 ms-could differentiate patients with cirrhosis from controls.

METHODS

This retrospective study included 160 patients with cirrhosis and 160 controls assessed between January 2010 and October 2022. SRT and RA were evaluated using a ruler drop paradigm and compared using propensity score matching. Factors distinguishing patients with cirrhosis from controls were assessed using logistic regression and receiver operating characteristics curve (ROC) analyses.

RESULTS

Propensity score matching identified 112 participants in each group with comparable baseline characteristics. As compared with controls, patients with cirrhosis exhibited significantly prolonged SRT (200 vs. 174 ms; P < 0.001) and diminished total RA (63% vs. 73%; P < 0.001). After adjustment for confounding factors, SRT and RA independently identified patients with cirrhosis. ROC analyses showed that SRT more effectively identified patients with cirrhosis than did the number-connection test/trail-making test-B (area under the curve, 0.87 vs. 0.60; P < 0.001).

CONCLUSIONS

Patients with cirrhosis demonstrated impairments in short-latency cognitive function. Given that SRT and RA are associated with balance, falls, and response to perturbation, these parameters may present a task-specific method to identify patients with cirrhosis at high risk of falls and motor vehicle crashes. Geriatr Gerontol Int 2024; 24: 25-31.

Novel Clean End-to-End Anastomosis Method, Without Opening the Stomach Lumen, in Totally Laparoscopic or Robotic Pylorus-Preserving Gastrectomy

PURPOSE

Intra-abdominal infection is a common postoperative complication of laparoscopic pylorus-preserving gastrectomies (PPGs). Many studies have reported that intra-abdominal infectious complications after gastrectomy adversely affect patient survival outcomes. To prevent gastric fluid leakage into the abdominal cavity, we developed a novel anastomosis method in which the stomach lumen is not opened (termed the non-opened clean end-to-end anastomosis method [NoCEAM]) and evaluated its feasibility.

MATERIALS AND METHODS

Subsequent to lymphadenectomy, the oral and anal resection lines were sutured using an intraoperative endoscope. After closing the stomach circumferentially with clips, the specimen was rolled outward like a "donut." We resected the specimen circumferentially using a linear stapler, and anastomosis was completed simultaneously. We examined the feasibility of this procedure ex vivo, using three porcine stomachs, and in vivo, using one pig. Subsequently, we applied the procedure to 13 consecutive patients with middle-third early gastric cancer utilizing laparotomic, laparoscopic, and robotic PPG.

RESULTS

NoCEAM was completed in all porcine models and human cases. In the human cases, the mean operation time (±standard deviation) was 279±51 minutes, and mean blood loss volume was 22±45 mL. The mean number of linear staples used was 5.06±0.76. None of the patients had complications, and all were discharged on the eighth postoperative. The serum total protein, serum albumin, and hemoglobin levels did not change significantly after surgery.

CONCLUSIONS

NoCEAM is feasible and safe for performing totally laparoscopic or robotic PPG. It may reduce postoperative complications, such as intra-abdominal infections.

POS0586 DIAGNOSIS OF MENTAL DISORDER COMPLICATED BY RHEUMATOID ARTHRITIS: A STUDY OF THE VALIDITY OF A PSYCHIATRIST’S DIAGNOSIS AND QUESTIONNAIRE METHOD

Background

It has been reported that about 15% of patients with rheumatoid arthritis (RA) have depression, and most of these studies have used questionnaire methods. Most of the studies have used questionnaires for depression. Because the depression questionnaire includes questions about physical symptoms, it is necessary to be careful in interpreting the results when there is an underlying disease. In addition, there are no studies on other mental disorders.

Objectives

In this study, we examined the validity of the questionnaire method for the diagnosis of RA complicated by psychiatric disorders.

Methods

Forty-nine outpatients with RA who agreed to participate in this study were included. Age, gender, type of Disease-modifying anti-rheumatic drugs, prednisolone use, presence of diabetes, hypertension, dyslipidemia, and CRP were investigated. The Patient Health Questionnaire-9 (PHQ-9) and Center for Epidemiologic Studies Depression Scale (CES-D) questionnaires were used; a score of 10 or more on the PHQ-9 and 16 or more on the CES-D was considered a cutoff. The psychiatrist was blinded to the results of the questionnaire and conducted a structured interview in a separate room. The psychiatrist’s diagnosis was defined as the Gold Standard, and was compared with the PHQ-9 and CES-D.

Results

Psychiatrist’s diagnosis was abnormal in 9 patients. This included one patient with major depression, one patient with moderate depression, two patients with minor depression, and two patients with adjustment disorder. The PHQ-9 had a specificity of 98%, a sensitivity of 33%, a positive predictive value of 75%, and a negative predictive value of 87%. The CES-D had a specificity of 82%, a sensitivity of 100%, a positive predictive value of 56%, and a negative predictive value of 100%.

Conclusion

The PHQ-9 and CES-D may be useful in screening for psychiatric disorders including associated with RA.

Disclosure of Interests

None declared.

AB0256 EFFECTS OF BIOLOGICAL-DMARDs ON THE SERUM URIC ACID LEVEL IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Hyperuricemia associated with rheumatoid arthritis (RA) has been reported to be a risk factor for cardiovascular disease. It has been reported that uric acid (UA) levels decrease with the use of leflunomide and increase with tumor necrosis factor (TNF) inhibitor therapy. However, the effects of long-term biological disease-modifying antirheumatic drugs (bDMARDs) therapy and the effects of non-TNF inhibitor biologic therapy on UA levels have not been reported.

Objectives

We aimed to investigate the changes in UA levels during the use of TNF inhibitors and non-TNF inhibitors therapy.

Methods

Patients with RA treated with bDMARDs from 2008 to 2018 were studied based on the All Showa University of RA (ASHURA) database. The association between uric acid level reduction and treatment was evaluated. Of 629 patients treated with the bDMARDs, 256 patients with available uric acid levels medical records were included. The following background factors were investigated: age; sex; type of bDMARDs; dosage of methotrexate and prednisolone; usage of conventional synthetic DMARDs, dyslipidemia drugs and nonsteroidal anti-inflammatory drugs; body mass index; smoking history; HbA1c; presence or absence of hypertension and dyslipidemia; and serum creatinine, C-reactive protein, and matrix metalloproteinase-3 levels. We also used the simplified disease activity index (SDAI) to evaluate RA disease activity. The analysis was performed in two groups, TNF inhibitor-treated group (148 patients) and non-TNF inhibitor-treated group (108 patients, tocilizumab and abatacept).　The primary endpoint was UA levels before, and after 6 months and 1 year, which was determined using the repeated-measures analysis of variance (ANOVA) and secondary endpoint was proportion of patients with hyperuricemia (uric acid level of 7.0 or higher was defined), determined using spearman’s correlation coefficient by rank test.

Results

In TNF inhibitor-treated group, the UA levels were not increased from 4.9 ± 1.4 (mg/dl) to 4.9 ± 1.4 and 5.1 ± 1.7 before treatment and after 6 months and 1 year, respectively (p=0.50). The number of patients with hyperuricemia increased from 7 to 12 and 16 (p=0.026). In non- TNF inhibitor-treated group, the UA levels were not increased from 5.2 ± 1.4 (mg/dl) to 5.2 ± 1.4 and 5.3 ± 1.4 (p=0.78). The number of patients with hyperuricemia increased from 8 to 16 and 12 (p=0.193). There was a difference in the type of drug, but no difference in the duration of administration by repeated-measures ANOVA.

Conclusion

Our study suggests that TNF inhibitor therapy may affect increased percentage of patients with hyperuricemia. On the other hand, non-TNF inhibitor therapy may not affect increased percentage of patients with hyperuricemia and bDMARD treatment has a mild effect on UA levels in patients with RA.

Acknowledgements

Nobuyuki Yajima, Takeo Isozaki, Kuninobu Wakabayashi, Sakiko Isojima, Ryo Takahashi, Hidekazu Furuya, Takahiro Tokunaga, Sho Ishii, Shinya Seki, Mayu Saito, Shinichiro Nishimi, Airi Nishimi, Yuzo Ikari, Mika Hatano, Tomoki Hayashi, Masahiro Hosonuma, Yoichi Toyoshima and Katsunori Inagaki, Kosuke Sakurai

Disclosure of Interests

None declared

AB0246 EXAMINATION OF THE FACTORS CONSTITUTING DEPRESSIVE STATE IN RHEUMATOID ARTHRITIS PATIENTS AND THEIR ASSOCIATIONS

Background

About 15% of patients with rheumatoid arthritis (RA) have depression, with an odds ratio of 1.42 (95% CI: 1.3-1.5) compared with healthy control. In previous reports, depressed mood and sleep disorders were reported separately, and no report has examined the factors that constitute depression. In addition, there is no report that examines the relationship between them.

Objectives

In the present study, we investigated the factors that constitute depression in RA patients.

Methods

One hundred and twenty-four patients with RA attending Showa University Hospital who gave written consent to the study were included in the study. Age, gender, body mass index, smoking history, presence of hypertension, presence of diabetes, steroid use, methotrexate use, erythrocyte sedimentation rate, CRP, and serum MMP-3 levels were investigated. The simplified disease activity index (SDAI) was used to assess disease activity in RA, the health assessment questionnaire disability index (HAQ-DI) was used to assess activity of daily living, and the Hamilton depression rating scale (HAM-D) was used to assess depression. All patients were interviewed for the HAM-D by the same interviewer, and the relationship between each item of the HAM-D and each index was examined.

Results

Forty-two patients (33.9%) reported experiencing “Depressed mood”. On the other hand, a higher percentage of patients reported “Anxiety Somatic (79, 63.7%),” “ Somatic Symptoms General (69, 55.6%),” “Work and Activities (57, 46.0%),” “Hypochondriasis (53, 42.7%),” and “Genital Symptoms (49, 36.5%)” than depressed mood. Depressed mood” was correlated with SDAI (r=0.31) and HAQ-DI (r=0.26), while “ Somatic Symptoms General “ was correlated with SDAI (r=0.30) and HAQ-DI (r=0.29). “Somatic Symptoms General” correlated with SDAI (r=0.30) and HAQ-DI (r=0.29). “Anxiety Somatic” correlated only with age (r=0.24), and other factors showed no correlation.

Conclusion

Higher percentage of RA patients reported “Somatic Symptoms” than “ Depressed mood “ as a factor of depression. These factors were mildly correlated with RA disease activity and HAQ-DI.

Disclosure of Interests

None declared

Spontaneous intranasal tumours in rabbits: 7 cases (2007-2019)

OBJECTIVES

Neoplasms that arise in the nasal cavity are reported infrequently in rabbits. This case series aims to review and determine the clinical behaviour of neoplasms in the nasal cavity in rabbits.

MATERIALS AND METHODS

A retrospective study was conducted on seven pet rabbits diagnosed with intranasal tumours to describe the clinical and histopathological findings and prognoses after surgery and/or radiotherapy.

RESULTS

The most common clinical signs were nasal snoring when breathing, nasal discharge, and subsequent dyspnoea and anorexia. Six different histopathological types of tumours were diagnosed: intranasal adenocarcinoma, squamous cell carcinoma, osteosarcoma, carcinoid tumour, osteoma, and lymphoma. Skull radiography only revealed the abnormalities in three of seven cases but on CT, the intranasal masses were more clearly identified in all cases. All cases received tumour resection through rhinostomy and four cases received radiotherapy after surgery. In the six cases with a known outcome, the survival time after surgery was more than 13 months.

CLINICAL SIGNIFICANCE

This case series provides an insight of the behavior of intranasal neoplasms in rabbits. Surgical treatment and radiotherapy could improve their clinical sings.

Histological and Immunohistochemical Features of Normal Histiocytes and Langerhans Cells, and Histiocytic Sarcomas in Four-Toed Hedgehogs (Atelerix albiventris)

Histiocytic sarcoma (HS) is a haematopoietic tumour of histiocyte origin that has been sporadically reported in four-toed hedgehogs (Atelerix albiventris). The present study aimed to investigate clinical, gross, histopathological and immunohistochemical features of HS in eight hedgehogs. Histological and immunohistochemical features of normal histiocytes and Langerhans cells (LCs) of hedgehogs were also investigated. HLA-DR-, Iba-1- and E-cadherin-positive LCs were observed in the epidermis, while Iba-1- and CD204-positive histiocytes were detected in the lymph nodes and spleen of normal hedgehogs. Localized HS (six cases) developed in the skin and spleen, while disseminated HS (two cases) occurred in the intestine. Tumour cells of disseminated HS were also distributed within the mesenteric lymph nodes, liver, kidney, spleen, lung and adrenal glands. Tumour cells of both localized and disseminated HS were composed of histiocytic cells, spindle to pleomorphic cells, multinucleated giant cells and erythrophagocytic cells. Most tumour cells were immunopositive for Iba-1, CD204 and lysozyme. A small number of tumour cells were positive for E-cadherin and CD208, and the tumour cells in one case were positive for HLA-DR. These results suggest that the tumour cells have variable features of histiocyte origin, including dendritic cells, LCs and macrophages. The behaviour of HS in the hedgehog was very aggressive, and 50% of cases died within 90 days of resection. The present study also highlighted the tendency for local tumour recurrence in localized cutaneous HS cases, suggesting a requirement for a long-term follow-up after excision.

The suppressive effect on CD4 T cell alloresponse against endothelial HLA-DR via PD-L1 induced by anti-A/B ligation

While donor-specific human leukocyte antigen (HLA) antibodies are a frequent cause for chronic antibody-mediated rejection in organ transplantation, this is not the case for antibodies targeting blood group antigens, as ABO-incompatible (ABO-I) organ transplantation has been associated with a favorable graft outcome. Here, we explored the role of CD4 T cell-mediated alloresponses against endothelial HLA-D-related (DR) in the presence of anti-HLA class I or anti-A/B antibodies. CD4 T cells, notably CD45RA-memory CD4 T cells, undergo extensive proliferation in response to endothelial HLA-DR. The CD4 T cell proliferative response was enhanced in the presence of anti-HLA class I, but attenuated in the presence of anti-A/B antibodies. Microarray analysis and molecular profiling demonstrated that the expression of CD274 programmed cell death ligand 1 (PD-L1) increased in response to anti-A/B ligation-mediated extracellular signal-regulated kinase (ERK) inactivation in endothelial cells that were detected even in the presence of interferon-γ stimulation. Anti-PD-1 antibody enhanced CD4 T cell proliferation, and blocked the suppressive effect of the anti-A/B antibodies. Educated CD25⁺ CD127^- regulatory T cells (edu.T_regs ) were more effective at preventing CD4 T cell alloresponses to endothelial cells compared with naive T_reg ; anti-A/B antibodies were not involved in the T_reg -mediated events. Finally, amplified expression of transcript encoding PD-L1 was observed in biopsy samples from ABO-I renal transplants when compared with those from ABO-identical/compatible transplants. Taken together, our findings identified a possible factor that might prevent graft rejection and thus contribute to a favorable outcome in ABO-I renal transplantation.

P5639Risk stratification for mortality using electrocardiographic markers based on 24-hour holter recordings: the JANIES-SHD study

Background

Recent guidelines have stated that reduced left ventricular ejection fraction (LVEF) is the gold standard marker for identifying patients at risk for cardiac mortality. Although reduced LVEF identifies patients at an increased risk of cardiac arrest, sudden cardiac deaths (SCDs) occur considerably more often in patients with relatively preserved LVEF. Current guidelines on SCD risk stratification do not adequately cover this general population pool. Several noninvasive electrocardiographic (ECG) risk stratifiers that reflect depolarization abnormality, repolarization abnormality, and autonomic imbalance have been evaluated so far. With current therapeutic advances using new medicines or devices, an LVEF is often preserved in patients with structural heart disease (SHD). However, the usefulness of noninvasive ECG markers for risk stratification in such a patient population has not yet been elucidated.

Purpose

This study aimed to assess clinical indices and ECG markers based on 24-hour Holter ECG recordings for predicting cardiac mortality in patients with SHD who have left ventricular dysfunction (LVD) but relatively preserved LVEF.

Methods

In total, 1,829 patients were enrolled into the Japanese Multicenter Observational Prospective Study (JANIES study). In this study, we analyzed data of 719 patients (569 men, age 64±13 years) with SHD including mainly ischemic heart disease (65.8%). As ECG markers based on 24-hour Holter recordings, nonsustained ventricular tachycardia (NSVT), ventricular late potentials, and heart rate turbulence (HRT) were assessed. The primary endpoint was all-cause mortality, and the secondary endpoint was fatal arrhythmic events.

Results

During a mean follow-up of 21±11 months, all-cause mortality was eventually observed in 39 patients (5.4%). Among those patients, 32 patients (82%) suffered from cardiac causes such as heart failure and arrhythmia. Multivariate Cox regression analysis showed that after adjustment for age and LVEF, documented NSVT (hazard ratio=2.82, 95% confidence interval [CI]: 1.38–5.76, P=0.005) and abnormal HRT (hazard ratio=2.31, 95% CI: 1.15–4.65, P=0.02) were significantly associated with the primary endpoint. These two ECG markers also had significant predictive values with the secondary endpoint. The combined assessment documented NSVT and abnormal HRT improved predictive accuracy.

Conclusion

This study demonstrated that combined assessment of documented NSVT and abnormal HRT based on 24-hour Holter ECG recordings are recommended for predicting future serious events in SHD patients who have relatively preserved LVEF.

Acknowledgement/Funding

Grants-in-Aid (21590909, 24591074, and 15K09103 to T.I.) for Scientific Research from the Ministry of Education, Culture, Sports, Science, and Technol

Identification of candidates for driver oncogenes in scirrhous-type gastric cancer cell lines

Scirrhous‐type gastric cancer (SGC) is one of the most intractable cancer subtypes in humans, and its therapeutic targets have been rarely identified to date. Exploration of somatic mutations in the SGC genome with the next‐generation sequencers has been hampered by markedly increased fibrous tissues. Thus, SGC cell lines may be useful resources for searching for novel oncogenes. Here we have conducted whole exome sequencing and RNA sequencing on 2 SGC cell lines, OCUM‐8 and OCUM‐9. Interestingly, most of the mutations thus identified have not been reported. In OCUM‐8 cells, a novel CD44‐IGF1R fusion gene is discovered, the protein product of which ligates the amino‐terminus of CD44 to the transmembrane and tyrosine‐kinase domains of IGF1R. Furthermore, both CD44 and IGF1R are markedly amplified in the OCUM‐8 genome and abundantly expressed. CD44‐IGF1R has a transforming ability, and the suppression of its kinase activity leads to rapid cell death of OCUM‐8. To the best of our knowledge, this is the first report describing the transforming activity of IGF1R fusion genes. However, OCUM‐9 seems to possess multiple oncogenic events in its genome. In particular, a novel BORCS5‐ETV6 fusion gene is identified in the OCUM‐9 genome. BORCS5‐ETV6 possesses oncogenic activity, and suppression of its message partially inhibits cell growth. Prevalence of these novel fusion genes among SGC awaits further investigation, but we validate the significance of cell lines as appropriate reagents for detailed genomic analyses of SGC.

Broad-spectrum antibiotic prescriptions are discontinued unevenly throughout the week

In order to investigate prescribing patterns of in-hospital broad-spectrum antibiotics (antimeticillin-resistant Staphylococcus aureus drugs, carbapenems and piperacillin/tazobactam), data on the distribution of antibiotic initiation and discontinuation throughout the week were analysed at Osaka University Hospital, Japan. No significant differences in the number of initiations were found between weekdays. However, broad-spectrum antibiotics were disproportionately discontinued on Tuesdays or on the second day after a holiday. This study suggests that broad-spectrum antibiotics tend to be continued over weekends or holidays and discontinued thereafter; this is likely to be due to behavioural factors beyond medical indications, and needs to be addressed in future antimicrobial stewardship initiatives.

The Prevalence and Implication of Zinc Deficiency in Patients With Chronic Liver Disease

Background

Patients with liver cirrhosis often exhibit zinc deficiency. Although zinc is involved in many bioactivities, many aspects of clinical implications of zinc deficiency in liver cirrhosis remain unclear. We aimed to reveal the prevalence and implications of zinc deficiency in liver cirrhosis by assessing associations with parameters such as clinical symptoms and laboratory data.

Methods

In 235 cirrhosis patients enrolled at multiple medical institutions in 2009, we assessed how blood zinc levels were associated with their clinical symptoms, patients characteristics, and liver function test results.

Results

Blood zinc levels were most strongly correlated with blood albumin levels among the study parameters (r = 0.587, P < 0.0001). When blood albumin levels were ≤ 3.5 g/dL, blood zinc levels were < 70 μg/dL in 88% of patients. Additionally, significant correlations were observed with age (r = -0.253, P = 0.0014), aspartate aminotransferase levels (r = -0.254, P = 0.0020), total bilirubin levels (r = -0.222, P = 0.0053), prothrombin time (r = -0.255, P = 0.0029), branched-chain amino acid to tyrosine ratio (r = 0.357, P < 0.0001), Child-Pugh score (r = 0.469, P < 0.0001), ammonia levels (r = -0.246, P = 0.0028), and total cholesterol levels (r = 0.314, P < 0.0001). Blood zinc levels were significantly lower in patients with edema/ascites (P < 0.0001), those with hepatic encephalopathy (P = 0.0215), those receiving oral diuretics (P = 0.0045), and those receiving oral branched-chain amino acids (P < 0.0001) than in those without these conditions.

Conclusions

Zinc deficiency is prevalent in cirrhosis patients, whereas nitrogen metabolic disorders, particularly hypoalbuminemia, can be an indicator of zinc deficiency. Thus, cirrhosis patients exhibiting a nitrogen metabolic disorder should be examined for the presence of zinc deficiency.

Effect of ELAD Liver Support on Plasma HGF and TGF–β1 in Acute Liver Failure

The aim of this study was to investigate the effects of treatment with the extracorporeal liver assist device (ELAD) in patients with acute liver failure (ALF) on plasma hepatocyte growth factor (HGF), the most potent growth factor, and transforming growth factor-β1 (TGF-β1), an inhibitory factor for liver regeneration. Initial plasma HGF, measured by ELISA, was significantly increased in the ALF patients (7.86 ± SEM 1.76 ng/ml) compared with normal subjects (0.10 ± 0.02 ng/ml, p<0.001). After 6 hours of ELAD haemoperfusion, plasma HGF increased further (30.5 ± 6.19 ng/ml, p<0.001), with a subsequent decrease towards the initial value by 48 hours. Initial plasma levels of TGF-β1 determined by ELISA were significantly increased in the ALF patients (43.4 ± 5.9 ng/ml) compared with normal subjects (25.1 ± 2.3 ng/ml, p<0.01), but there was no change in plasma TGF-β1 during the study period in either the ELAD or control ALF group. As HGF is a heparin-binding growth factor and similar changes in HGF were observed during CVVHD, one possible explanation is that heparin administered as anticoagulant for extracorporeal circulation is involved in the effects observed on HGF.

Divergent clinical outcomes of alpha-glucosidase enzyme replacement therapy in two siblings with infantile-onset Pompe disease treated in the symptomatic or pre-symptomatic state

Pompe disease is an autosomal recessive, lysosomal glycogen storage disease caused by acid α-glucosidase deficiency. Infantile-onset Pompe disease (IOPD) is the most severe form and is characterized by cardiomyopathy, respiratory distress, hepatomegaly, and skeletal muscle weakness. Untreated, IOPD generally results in death within the first year of life. Enzyme replacement therapy (ERT) with recombinant human acid alpha glucosidase (rhGAA) has been shown to markedly improve the life expectancy of patients with IOPD. However, the efficacy of ERT in patients with IOPD is affected by the presence of symptoms and cross-reactive immunologic material (CRIM) status.

We have treated two siblings with IOPD with ERT at different ages: the first was symptomatic and the second was asymptomatic. The female proband (Patient 1) was diagnosed with IOPD and initiated ERT at 4 months of age. Her younger sister (Patient 2) was diagnosed with IOPD at 10 days of age and initiated ERT at Day 12. Patient 1, now 6 years old, is alive but bedridden, and requires 24-hour invasive ventilation due to gradually progressive muscle weakness. In Patient 2, typical symptoms of IOPD, including cardiac failure, respiratory distress, progressive muscle weakness, hepatomegaly and myopathic facial features were largely absent during the first 12 months of ERT. Her cardiac function and mobility were well-maintained for the first 3 years, and she had normal motor development. However, she developed progressive hearing impairment and muscle weakness after 3 years of ERT. Both siblings have had low anti-rhGAA immunoglobulin G (IgG) antibody titers during ERT and have tolerated the treatment well.

These results suggest that initiation of ERT during the pre-symptomatic period can prevent and/or attenuate the progression of IOPD, including cardiomyopathy, respiratory distress, and muscle weakness for first several years of ERT. However, to improve the long-term efficacy of ERT for IOPD, new strategies for ERT for IOPD, e.g. modifying the enzyme to enhance uptake into skeletal muscle and/or to cross the blood brain barrier (BBB), will be required.

A Concept of Cross-Ferroic Plasma Turbulence

The variety of scalar and vector fields in laboratory and nature plasmas is formed by plasma turbulence. Drift-wave fluctuations, driven by density gradients in magnetized plasmas, are known to relax the density gradient while they can generate flows. On the other hand, the sheared flow in the direction of magnetic fields causes Kelvin-Helmholtz type instabilities, which mix particle and momentum. These different types of fluctuations coexist in laboratory and nature, so that the multiple mechanisms for structural formation exist in extremely non-equilibrium plasmas. Here we report the discovery of a new order in plasma turbulence, in which chained structure formation is realized by cross-interaction between inhomogeneities of scalar and vector fields. The concept of cross-ferroic turbulence is developed, and the causal relation in the multiple mechanisms behind structural formation is identified, by measuring the relaxation rate and dissipation power caused by the complex turbulence-driven flux.

The effect of aprepitant and dexamethasone combination on paclitaxel-induced hypersensitivity reaction

PURPOSE OF INVESTIGATION

Dexamethasone (DEX) is often administered to prevent paclitaxel (PTX)-induced hypersensitivity reactions (HSR). The DEX dose is reduced when administered in combination with aprepitant (APR). However, the influence of that dose reduction on PTX-induced HSR has not been thoroughly studied. The present authors aimed to investigate the effects of the combined administration of APR and DEX on PTX-induced HSR.

MATERIALS AND METHODS

Fifty-one patients who received a three-week PTX regimen in combination with APR and DEX were retrospectively analysed. The authors compared the dose of DEX with the incidence of HSR and other toxicities.

RESULTS

Patients were stratified into two groups depending on the DEX dose, > 20 mg (group D, 33 patients), and < 12 mg (group reD, 26 patients). The incidence of HSR in Groups D and reD were 51.5% (17/33) and 53.8% (14/26), respectively. The frequencies of other toxicities between the groups were comparable.

CONCLUSION

The findings suggest that although a reduction in DEX dose is possible when APR is co-administered, this does not affect the PTX-induced HSR. However, adverse effect should be closely monitored.

Branched-chain amino acids prevent hepatocarcinogenesis and prolong survival of patients with cirrhosis

BACKGROUND & AIMS

Although a low plasma level of branched-chain amino acids (BCAAs) is a marker of cirrhosis, it is not clear whether BCAA supplements affect disease progression. We performed a multicenter study to evaluate the effects of BCAA supplementation on hepatocarcinogenesis and survival in patients with cirrhosis.

METHODS

We enrolled 299 patients from 14 medical institutions in Japan in a prospective, multicenter study in 2009; 267 patients were followed through 2011. Patients were given BCAA supplements (5.5-12.0 g/day) for more than 2 years (n = 85) or no BCAAs (controls, n = 182). The primary end points were onset of hepatocellular carcinoma (HCC) and death. Factors associated with these events were analyzed by competing risk analysis.

RESULTS

During the study period, 41 of 182 controls and 11 of 85 patients given BCAAs developed HCC. On the basis of the Cox and the Fine and Gray models of regression analyses, level of α-fetoprotein, ratio of BCAA:tyrosine, and BCAA supplementation were associated with development of HCC (relative risk for BCAAs, 0.45; 95% confidence interval, 0.24-0.88; P = .019). Sixteen controls and 2 patients given BCAAs died. Factors significantly associated with death were Child-Pugh score, blood level of urea nitrogen, platelet count, male sex, and BCAA supplementation (relative risk of death for BCAAs, 0.009; 95% confidence interval, 0.0002-0.365; P = .015) in both regression models.

CONCLUSIONS

On the basis of a prospective study, amino acid imbalance is a significant risk factor for the onset of HCC in patients with cirrhosis. BCAA supplementation reduces the risk for HCC and prolongs survival of patients with cirrhosis.

Relationship between psychological factors and arthralgia in patients with rheumatoid arthritis

Abstract Various factors were assessed in terms of their contribution to arthralgia in a rheumatoid arthritis patient. Eighty-two outpatients (62 women and 20 men) with rheumatoid arthritis (RA) were examined with respect to the subjective degree of arthralgia, age, disease duration, dysfunction, steroid dose, steroid period, depression, anxiety, extroversion, neurotic disorder, and number of caretakers. The results were explained on the basis of stepwise regression analysis and psychological and clinical data. We analyzed results of a correlation coefficient test on the mutual relationship between variables. Stepwise regression analysis was performed to assess factors of arthralgia in terms of "depression," "mean activity," "morning stiffness," and "steroid dose." Depression is a factor of arthralgia as shown in this study, but it is clear that other factors are also involved. Anxiety was a factor distinct from the activity of RA. The factor contributing most to arthralgia was found to be depression, whereas anxiety had no effect.

A large-scale nationwide multicenter prospective observational study of triple therapy using rabeprazole, amoxicillin, and clarithromycin for Helicobacter pylori eradication in Japan

BACKGROUND

In recent years in Japan, the rate of clarithromycin (CAM) resistance in Helicobacter pylori has risen to around 30%, and the eradication rate with triple therapy [proton pump inhibitor + amoxicillin (AMPC) + CAM] has been trending downward to around 70%. In 2007, rabeprazole (RPZ)-based triple therapy (RPZ + AMPC + CAM: RAC therapy) was approved in Japan, and a large-scale nationwide study was therefore initiated to evaluate the efficacy and safety of RAC therapy in clinical practice.

METHODS

Patients with H. pylori-positive gastric/duodenal ulcer (including ulcer scars) were administered triple therapy comprising RPZ 10 mg, AMPC 750 mg, and CAM 200 mg (or 400 mg), twice daily for 7 days.

RESULTS

The eradication rate was 80.7% (2,551/3,162). The results of multivariate analysis indicated the following as factors affecting the eradication rate: sex, treatment compliance, history of H. pylori treatment, presence of urologic disease, presence of respiratory disease, and year of starting treatment. The incidence of adverse drug reactions (such as diarrhea and dysgeusia) was 4.4% (166/3,789). The results of multivariate analysis indicated the following as factors affecting the incidence of adverse drug reactions: sex, daily CAM dose, and history of allergies.

CONCLUSION

In a large-scale nationwide study of use in clinical practice, RAC therapy was confirmed to be effective and safe.

Prevalence of diabetes and incidence of angiopathy in patients with chronic viral liver disease

Patients with chronic liver disease (CLD) often develops glucose intolerance. We explored the prevalence of diabetes mellitus in viral CLD, and analyzed factors profoundly affecting the diabetic angiopathies. 229 CLD patients (124 chronic hepatitis and 105 liver cirrhosis) entered the study. The diagnosis of diabetes was made with the criteria by World Health Organization. Laboratory investigation included serum asparate aminotransferase, alanine aminotransferase, albumin, fasting blood sugar, hemoglobin A1c (HbA1c), fasting immunoreactive insulin, and HOMA-R (FBS*IRI/405). The incidence of macro- and microangiopathy were also examined. Forty (17.5%) CLD patients were diagnosed diabetes, giving a significantly higher incidence than that of general cohort (5.3%) (p<0.001). Among them, 12 (30%) had the triopathy, significantly lower than that in a matched group of diabetic patients without CLD (65%) (p<0.001). Significantly increased levels of HbA1c and HOMA-R were observed in diabetic CLD with angiopathy compared with diabetic CLD without. Incidence of diabetes was increased in viral CLD patients. The rate of diabetic angiopathies in CLD, however, was relatively low, this could be explained by low coagulability in these patients. Poor control of hyperglycemia, partly due to insulin resistance, might explain the onset of angiopathy in diabetic CLD.