Association between working overtime and psychological stress reactions in elementary and junior high school teachers in Japan: a large-scale cross-sectional study.

This study aimed to investigate the relationship between working overtime and psychological stress reactions among school teachers. It also evaluated the interaction of overtime work types (on weekdays, on holidays, and bringing work home) and task content (educational, peripheral and both). This cross-sectional study was conducted on Japanese elementary and junior high school teachers. Primary outcome was psychological stress reactions measured with the Brief Job Stress Questionnaire. Participants were asked how long they work overtime on weekdays, holidays, and at home. Participants were also asked whether they engaged in educational tasks and/or peripheral tasks during that overtime work. Multiple linear regression analyses were applied and 6,135 participants were included in the analyses after imputing missing data. Working hours of all three types were significantly correlated with higher psychological stress reactions. Moreover, engaging in both educational and peripheral tasks showed higher psychological stress reactions than in only educational tasks when working overtime on weekdays and holidays. In conclusion, reducing overtime work regardless of work types is crucial for mitigating psychological stress reactions for teachers. It might also be possible to manage the psychological stress reactions by splitting the role of task contents, when working overtime on weekdays and holidays at school.

Roles of Angioplasty With Drug-Coated Balloon for Chronic Ischemia in Wound Healing.

PURPOSE: Clinical trials have demonstrated sustained benefits of drug-coated balloon (DCB) angioplasty compared with noncoated balloon angioplasty in symptomatic peripheral artery disease (PAD) presenting with femoropopliteal (FP) artery disease. However, there is still controversy whether particulate embolization caused by crystalline paclitaxel, the so-called "downstream effect," is adversely associated with clinical outcomes after use of FP DCB among chronic limb-threatening ischemia (CLTI) patients. The current RADISH (Roles of Angioplasty with Drug-coated balloon for chronic ISchemia in wound Healing) study investigated wound healing following DCB therapy vs non-DCB therapy for real-world CLTI patients presenting with FP lesions. MATERIALS AND METHODS: This multicenter, retrospective study analyzed 927 patients with CLTI (mean age, 76±10 years; male, 57.8%; diabetes mellitus, 64.5%; dialysis, 50.7%) presenting with FP lesions and treated endovascularly via DCB (138 patients) vs non-DCB therapy (789 patients) between April 2014 and March 2019. The primary outcome measure was 1-year wound healing, while the secondary outcome measure was 1-year primary patency. Clinically-driven target lesion revascularization (CD-TLR), limb salvage and overall survival were also analyzed by using propensity score matching analysis. RESULTS: The propensity score matching extracted 111 pairs (as many patients in the DCB group and 629 patients in the non-DCB group). The 1-year cumulative incidence of wound healing (95% CI) was 74.4% (62.6% to 82.5%) in the DCB group and 71.9% (60.4% to 80.1%) in the non-DCB group, with no significant intergroup difference (p=0.93). The DCB group had a higher rate of primary patency (p=0.002) and freedom from CD-TLR (p=0.010) than the non-DCB group, whereas there was no significant intergroup difference in limb salvage (p=0.21) or overall survival (p=0.93). CONCLUSION: The current analysis of data from the RADISH study demonstrated that DCB therapy did not lead to delayed wound healing and reduced restenosis rate in CLTI patients presenting FP lesions. From this results, DCB therapy would be a reasonable treatment option for CLTI patients.

Lumen Loss at 1 Year After Bare Nitinol Stent Implantation in the Superficial Femoral Artery.

PURPOSE: To investigate lumen loss (LL) at 1 year after bare nitinol stent (BNS) implantation for de novo superficial femoral artery (SFA) lesions. MATERIALS AND METHODS: The subjects were 701 consecutive patients (mean age 74±9 years; 492 men) with 817 de novo SFA lesions treated with BNS implantation between January 2004 and September 2015. The mean lesion length was 141±88 mm and the mean vessel diameter was 5.4±0.9 mm. The endpoint was LL at 1 year after BNS implantation. Secondary outcomes were restenosis and target lesion revascularization (TLR) estimated using the Kaplan-Meier method; estimates are reported with the 95% confidence interval (CI). LL was defined as the minimum lumen diameter immediately after BNS implantation minus that at 1 year measured by angiographic quantitative vessel analysis. The distribution of LL in the overall population was estimated using an accelerated failure time model. RESULTS: Mean LL at 1 year was estimated to be 1.74±1.28 mm (95% CI 1.63 to 1.84). Current smoking was positively associated with LL (p=0.015), whereas lack of cilostazol use was correlated with an increase in LL (p=0.001). Reference vessel diameter and lesion length did not have any significant association with LL at 1 year. The 1-year cumulative estimate of restenosis was 25% (95% CI 22% to 28%); the corresponding value for TLR was 18% (95% CI 15% to 21%). CONCLUSION: Mean LL progressed by at least 1.6 mm up to 1 year after BNS implantation. The risk factors for increased LL were current smoker and lack of cilostazol use.

Clinical impact of intravascular ultrasound-guided balloon angioplasty in patients with chronic limb threatening ischemia for isolated infrapopliteal lesion.

BACKGROUND: To estimate the impact of intravascular ultrasound (IVUS) in patients with chronic limb-threatening ischemia (CLTI) who underwent balloon angioplasty for isolated infrapopliteal lesion. METHODS: The study was performed as a single-center, prospective maintained database, retrospective analysis. Between January 2013 and December 2018, consecutive 155 CLTI patients (155 limbs) who primarily underwent balloon angioplasty for de novo isolated infrapopliteal atherosclerotic lesions with Rutherford category class 4 or 5 were identified (IVUS-guided: 92 patients, angio-guided: 63 patients) and included in the analysis. We compared clinical outcomes in IVUS-guided group with that in angio-guided group. The primary endpoint was limb salvage without any reintervention. The main secondary endpoints were wound healing rate and time to wound healing in the tissue loss group. RESULT: Patient and limb characteristics were similar between the two groups. The IVUS-guided group was treated with a larger balloon size for all types of below-the-knee vessel (p < .001), although lesion characteristics, including the QVA-measured vessel diameter, were similar between the two groups. The IVUS-guided group had a higher rate of limb salvage without any reintervention than the angio-guided group (p = 0028). Whereas limb salvage and overall survival was not significantly different. Wound healing was significantly earlier and the time to wound healing was significantly shorter (84 ± 55 days vs. 135 ± 118 days, p = .007) in the IVUS-guided group. CONCLUSION: Limb salvage rate without any reintervention in IIVUS-guided balloon angioplasty group was significantly higher than that in angio-guided balloon angioplasty group in patients with CLTI due to isolated infrapopliteal disease.

Combination therapy of heparin-bonded covered stent and bare-nitinol stent assessed by intravascular ultrasound.

To examine clinical outcomes for combination therapy of heparin-bonded covered stent [VIABAHN™ stent (VIA)] and bare-nitinol stent (BNS), and to determine independent predictors of restenosis after VIA implantation assessed by intravascular ultrasound (IVUS). A retrospective analysis was conducted on VIA use in the femoropopliteal artery of 71 patients (81 lesions) treated between June 2012 and November 2018. We divided the treated lesions into two groups; that is, whether BNS was added at the proximal site of the VIA or not (combination of VIA and BNS group [COM; n = 21] vs. VIA group [n = 60]). The median follow-up duration was 21.6 months (interquartile range, 13.2-28.8 months). Restenosis at 2 years was observed in 5 lesions (33%) in COM group and 17 lesions (38%) in VIA group (log-rank, P = 0.74). In VIA group, 14 lesions developed restenosis within 12 months. Multivariate logistic regression analysis of VIA group revealed that the proximal plaque burden was an independent predictor of restenosis within 12 months after VIA implantation (odds ratio 1.15, 95% confidence interval 1.01-1.30, P = 0.01), with the optimal cutoff value of 43% (area under the receiver operator characteristic curve 0.79, sensitivity 91%, specificity 69%). A remaining plaque of > 43% at the proximal reference segment was an independent predictor of restenosis after VIA implantation. When residual stenosis is observed at the proximal site of SFA after VIA implantation, combination therapy of VIA and BNS would be an optimal management.

Primary Use of the TruePath Crossing Device for Infrainguinal Chronic Total Occlusions With Intravascular Ultrasound Evaluation.

PURPOSE: To evaluate the use of the TruePath crossing device as the primary recanalization tool for infrainguinal chronic total occlusions (CTO). METHODS: A retrospective analysis was conducted of 50 patients (mean age 75 years; 26 men) with 55 infrainguinal CTOs treated with the TruePath between March 2017 and September 2017 at a single center. The mean occlusion length was 138±55 mm, and femoropopliteal lesions accounted for 65% of the 55 lesions. The primary outcome measure was CTO crossing using the TruePath alone; secondary outcomes were assisted success (>50% lumen gain using the TruePath), device-related complications, and intraluminal crossing evaluated by intravascular ultrasound (IVUS). RESULTS: Complete success was achieved in 33 (60%) of 55 lesions having a mean occlusion length of 145±72 mm. Among these, the true lumen crossing rate was 97% according to IVUS evaluation. Assisted success was achieved in 15 (68%) of the 22 failures. Complete/assisted success, in which the TruePath was thought to have contributed to CTO crossing, was attained in 48 (87%) of the 55 lesions. Three (5.5%) complications were observed: a perforation, an access-site hematoma, and acute occlusion; only the perforation was device related (1.8%). Multivariate analysis showed PACCS grade 4 (odds ratio 4.5, 95% confidence interval 1.33 to 15.5, p=0.02) was an independent predictor of TruePath failure. CONCLUSION: Primary use of the TruePath crossing device for infrainguinal CTOs demonstrated a satisfactory complete success rate and a high rate of IVUS-documented intraluminal crossing with few device-related complications. Severe calcification is an independent predictor of TruePath failure.

Hong Kong consumer preferences for Japanese beef: Label knowledge and reference point effects.

The excellent flavor of Wagyu is becoming increasingly popular all over the world. However, the popularity of Wagyu has encouraged competition for authentic Japanese Wagyu, resulting in the appearance of inauthentic Wagyu beef. To ward off this export competition, Japanese Wagyu producers need to improve and differentiate their value-added beef. As hardly any past studies focus on the consumption of Japanese Wagyu in Hong Kong, this paper uses a choice experiment to examine the valuation of beef by Hong Kong consumers in terms of country of origin. Data from 250 Hong Kong consumers obtained through a web questionnaire were used to analyze the beef preferences. In addition to the beef's country of origin, its marbling level, the Japanese Wagyu label and reference point effects were considered. The results indicate that Hong Kong consumers place a significant premium on Japanese Wagyu over Australian or American Wagyu. That premium is greater among consumers who have seen the Japanese Wagyu label. Reference price effects were also statistically confirmed. To promote Japanese Wagyu beef consumption, therefore, it is important to make the consumer aware of the advantages of Japanese Wagyu.

Central nervous system EBV lymphoproliferative disorder in a patient with rhabdomyosarcoma.

Epstein-Barr virus associated lymphoproliferative disorder (EBV-LPD) occurs in patients with immunodeficiency, but it has not been well described in patients who have received chemotherapy for solid tumors. We describe a child with rhabdomyosarcoma who developed isolated central nervous system (CNS) EBV-LPD during combination chemotherapy with vincristine, actinomycin D and cyclophosphamide. The patient was treated with high-dose methotrexate (HD-MTX) for CNS EBV-LPD and then treated with rituximab in addition to HD-MTX because of the emergence of LPD in the liver. I.v. rituximab combined with HD-MTX might be effective therapy for CNS EBV-LPD.

Follow-up of pediatric patients treated by IVIG for Langerhans cell histiocytosis (LCH)-related neurodegenerative CNS disease.

The follow-up of eight Japanese children with Langerhans cell histiocytosis (LCH)-related neurodegenerative central nervous system (ND-CNS) disease who were treated with intravenous immunoglobulin (IVIG) for >3 years is described. The patients developed ND-CNS disease at a median age of 5.2 (range 3.5-10.0) years and received IVIG treatment for a median duration of 6.5 + (range 3.7 to 10+) years. After a median follow-up period of 11.6 + (8.3+ to 13.9+) years after ND-CNS disease diagnosis, the median Expanded Disability Status Scale (EDSS) score of the eight patients was 4.0 (range 2.0-9.5). At the last follow-up as of March 2014, three patients have low EDSS scores (<3.0) and can walk without any assistance. Another three patients have EDSS scores of 3.5-4.5 and can walk by themselves, albeit occasionally with supports. However, the remaining two patients are wheelchair bound or bed ridden. The school performance of seven of the eight patients was below average. IVIG appeared to be most beneficial when it was administered soon after ND-CNS disease diagnosis when the EDSS scores were low (1.0-2.5). The patients who began receiving IVIG when their high EDSS scores were higher (4.5-7.0) appeared to obtain less benefit. To prevent progression of ND-CNS disease in patients with LCH, it is recommended to introduce IVIG early and to continue this therapy for >3 years.

Efficacy of prophylactic additional cranial irradiation and intrathecal chemotherapy for the prevention of CNS relapse after allogeneic hematopoietic SCT for childhood ALL.

We evaluated the efficacy of CRT and IT chemotherapy, in addition to conditioning including TBI, for the prevention of CNS relapse, in allogeneic HSCT for childhood ALL. From January 1999 to December 2009, a total of 48 patients, without previous or presenting CNS involvement, underwent HSCT for ALL. All patients received myeloablative conditioning including TBI of 12 or 13.2 Gy and IT chemotherapy twice between days -10 and -2 prior to HSCT. Twenty-five patients received CRT prior to TBI (CRT+), and 23 patients did not (CRT-). CRT+ and CRT- patients had a seven-yr EFS rate of 40.0 ± 9.8% and 41.7 ± 10.6%, respectively (p = 0.8252). The seven-yr relapse rates for CRT+ and CRT- patients were 45.0 ± 11.2% and 38.4 ± 11.6%, respectively (p = 0.7460). CNS relapses were evident in 1 (4.0%) CRT+ patient and 1 (4.4%) CRT- patient (p = 1.000). There were no significant differences in EFS and the probability of CNS relapse between CRT+ and CRT- patients. These results demonstrate that CRT and IT chemotherapy, in addition to conditioning chemotherapy, may not be necessary in childhood ALL patients without previous or presenting CNS involvement.

[Four cases of bevacizumab-related gastrointestinal perforation].

We report 4 cases of gastrointestinal perforation associated with systemic administration of bevacizumab. Case 1: A 51- year-old man with colorectal cancer (CRC) received mFOLFOX+bevacizumab (Bev). A small intestinal perforation occurred 7 days after Bev administration (Bev-a) and was successfully treated with omental packing. Case 2: A 50-year-old woman with CRC received capecitabine+Bev. A small intestinal perforation was detected 5 days after Bev-a, and was successfully treated with primary suture and an omental flap. Case 3: A 74-year-old man with CRC received CapeOX+Bev. A duodenal perforation occurred on the same day as Bev-a, but could be treated conservatively. Case 4: A 57-year-old man with lung cancer received DTX+Bev. A small intestinal perforation occurred 13 days after Bev-a, but this could be managed with primary suture and an omental flap. The gastrointestinal perforation presented with mild abdominal pain and was detected within 14 days after Bev-a in each of these 4 cases. Three patients were successfully treated with only minimal surgical procedures and 1 patient could be managed with conservative treatment for a perforated duodenal ulcer.

[Recurrent pulmonary edema after umbilical cord blood transplantation in a patient with infant acute lymphoblastic leukemia].

This report describes two infants with recurrent pulmonary edema after umbilical cord blood transplantation (CBT). A 3-month-old boy and a 7-month-old boy with infant acute lymphoblastic leukemia underwent CBT from an unrelated donor in the first complete remission. The conditioning regimen consisted of busulfan, etoposide, and cyclophosphamide. Tacrolimus and short-term methotrexate were administered for the prophylaxis of acute graft-versus-host disease (GVHD). Neutrophil engraftment was achieved on days 17 and 19, respectively. Neither infant developed acute GVHD. They both exhibited tachypnea and weight gain on days 25 and 30, respectively, which were diagnosed as pulmonary edema by chest X rays. The respiratory condition of the patients improved within a few days with the close monitoring of weight changes after the administration of diuretics. However, they suddenly developed dyspnea and pulmonary edema again on days 37 and 59, respectively. Steroid therapy was initiated for both patients. Their respiratory condition again improved quickly after the initiation of steroid therapy. Their symptoms and clinical courses may be classified as a new entity of idiopathic pneumonia syndrome (IPS). Therefore, these cases may represent a new unclassifiable IPS associated with either CBT or infants.

[Central intravenous catheter-related bacteremia due to Chryseobacterium indologenes after cord blood transplantation].

A 3-year-old girl with acute myeloid leukemia underwent unrelated cord blood stem cell transplantation (UCBT) due to primary induction failure. Fourteen days after UCBT, she developed central venous catheter (CVC)-related bloodstream infection due to Chryseobacterium indologenes. Despite ciprofloxacin and minocycline being administered according to the results of susceptibility, a high grade fever recurred. Therefore, the CVC was removed 21 days after UCBT and symptoms related to CVC infection improved. Although C. indologenes is widely distributed in nature, it is a rare pathogen in humans. Most cases of C. indologenes bacteremia have been found in immunocompromised patients with malignancies and diabetes mellitus. C. indologenes exhibits specific characteristics, including the progression of resistance to antibiotics and the formation of a biofilm. Therefore, removal of the CVC appears to be the most reasonable treatment for CVC infection due to C. indologenes in patients undergoing hematopoietic stem cell transplantation if clinical symptoms do not improve after appropriate antibiotic therapy.

Outcomes of immunological interventions for mixed chimerism following allogeneic stem cell transplantation in children with juvenile myelomonocytic leukemia.

BACKGROUND: For children with juvenile myelomonocytic leukemia (JMML) who undergo stem cell transplantation (SCT), the role of immunological interventions including withdrawal of immunosuppressive therapy (IST) and donor lymphocyte infusion (DLI) for treatment of disease recurrence remains uncertain. PROCEDURE: We analyzed serial chimerism status following SCT and evaluated the efficacy of immunological interventions for the management of mixed chimerism (MC) in children with JMML. RESULTS: Chimerism analysis was available in 26 SCT cases following the first and second SCT. MC was observed in 16 cases and withdrawal of IST was performed in 14 cases immediately after identification of MC. Donor lymphocyte infusion (DLI) was performed in five MC cases. Eight MC cases were observed at the time of neutrophil recovery. Following withdrawal of IST, three cases achieved complete chimerism (CC) while the proportion of autologous cells increased rapidly in the remaining five cases. Six MC cases were observed after achievement of hematological remission (HR) and responses to withdrawal of IST were observed in two cases. In the remaining four cases, despite withdrawal of IST, the proportion of autologous cells increased. Five cases received DLI but only one case responded. CONCLUSION: Although the benefits of immunological interventions for MC after SCT in JMML were limited, some patients did achieve HR as a result of these treatment modalities without a second SCT. Close monitoring of donor chimerism and early detection of MC is helpful in guiding treatment after SCT in children with JMML.

[Patient with pseudomyxoma peritonei in whom, hyperglycemia and hyponatremia were induced by massive intraperitoneal lavage with 5% glucose].

A 74-year-old woman was admitted to our hospital with weight loss and sense of abdominal distension. She was diagnosed to have pseudomyxoma peritonei based on careful examinations in the surgical department of our hospital. She therefore underwent elective surgery consisting of an ileocecal resection under general anesthesia. The induction of anesthesia was very smooth, but the patient's blood pressure became unstable during the operation. As a result, we inserted an arterial catheter into the radial artery, and the blood gas analysis showed severe hyperglycemia and hyponatremia. We determined that a massive amount of intraperitoneal lavage fluid with 5% glucose had been absorbed into the blood vessels. We administered regular insulin to manage the hyperglycemia and also mannitol and furosemide to treat the hyponatremia that had been caused by water intoxication. Thereafter, both the hyperglycemia and hyponatremia improved quickly, and the patient was extubated safely. We had little prior knowledge about pseudomyxoma peritonei, and therefore had not expected such an occurrence. Moreover we did not sufficiently provide the surgical team with all of the patient's information. In the future, we will maintain close cooperation with the surgical team and establish an appropriate anesthesia plan when we encounter patients presenting with pseudomyxoma peritonei.