Effect of woohwangchungsimwon and donepezil co-treatment on cognitive function and serum metabolic profiles in a scopolamine-induced model of Alzheimer's disease.

ETHNOPHARMACOLOGICAL RELEVANCE: Woohwangchungsimwon (WCW) is a traditional medicine used in East Asian countries to treat central nervous system disorders. Reported pharmacological properties include antioxidant effects, enhanced learning and memory, and protection against ischemic neuronal cell death, supporting its use in treating neurodegenerative diseases like Alzheimer's disease (AD). AIM OF THE STUDY: The study aims to assess the effects of co-treatment with WCW and donepezil on cognitive functions and serum metabolic profiles in a scopolamine-induced AD model. MATERIALS AND METHODS: Cell viability and reactive oxygen species (ROS) levels were measured in amyloid ß-peptide25-35 (Aß25-35)-induced SH-SY5Y cells. An AD model was established in ICR mice by intraperitoneal scopolamine administration. Animals underwent the step-through passive avoidance test (PAT) and Morris water maze (MWM) test. Hippocampal tissues were collected to examine specific protein expression. Serum metabolic profiles were analyzed using nuclear magnetic resonance (NMR) spectroscopy. RESULTS: Co-treatment with WCW and donepezil increased cell viability and reduced ROS production in Aß25-35-induced SH-SY5Y cells compared to that with donepezil treatment alone. Co-treatment improved cognitive functions and was comparable to donepezil treatment alone in the PAT and MWM tests. Pathways related to tyrosine, phenylalanine, and tryptophan biosynthesis, phenylalanine metabolism, and cysteine and methionine metabolism were altered by co-treatment. Levels of tyrosine and methionine, major serum metabolites in these pathways, were significantly reduced after co-treatment. CONCLUSIONS: Co-treatment with WCW and donepezil shows promise as a therapeutic strategy for AD and is comparable to donepezil alone in improving cognitive function. Reduced tyrosine and methionine levels after co-treatment may enhance cognitive function by mitigating hypertyrosinemia and hyperhomocysteinemia, known risk factors for AD. The serum metabolic profiles obtained in this study can serve as a foundation for developing other bioactive compounds using a scopolamine-induced mouse model.

Association between physical activity and risk of renal function decline and mortality in community-dwelling older adults: a nationwide population-based cohort study.

BACKGROUND: Physical activity (PA) is an important risk factor associated with health outcomes. However, the relationship between PA and kidney function decline in older adults remains unclear. We examined the influence of PA on kidney function decline and mortality in community-dwelling older adults. METHODS: Adults aged ≥ 65 years with an estimated glomerular filtration rate (eGFR) > 60 mL/min/1.73 m2 who had available health checkup data from 2009 to 2010 were included. The cohort was followed annually through December 2015 for anthropometric, sociodemographic, and medical information including outcomes and biennially for laboratory information from the health checkup. We divided these patients into three groups according to self-reported PA (Inactive group: no leisure-time PA, Active group: vigorous activity for at least 80 min/week or a sum of moderate-intensity activity and walking for at least 300 min/week, Low-active group: level of PA between the definitions of the other two groups). Associations between the intensity of PA and death, cardiovascular death, and ≥ 50% eGFR decline were investigated. RESULTS: Among 102,353 subjects, 32,984 (32.23%), 54,267 (53.02%), and 15,102 (14.75%) were classified into the inactive, low-active, and active groups, respectively. The active group was younger, contained a higher proportion of men, and had higher frequencies of hypertension, diabetes mellitus, drinking, and smoking than the other groups. The active group had significantly lower incidence rates of mortality, cardiovascular mortality, and kidney function decline than the other groups (all p < 0.001). The active group also showed lower all-cause (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.70-0.82) and cardiovascular mortality (HR, 0.64; 95% CI, 0.53-0.78) and protection against ≥ 50% eGFR decline (HR, 0.81; 95% CI, 0.68-0.97) compared with the inactive group in the fully adjusted Cox proportional hazards regression model. CONCLUSIONS: High PA was an independent modifiable lifestyle factor for reducing mortality and protecting against declines in kidney function in older adults.

Association between behavioral patterns and mortality among US adults: National Health and Nutrition Examination Survey, 2007-2014.

Few large-scale studies have been conducted to show the joint effects of mortality associated with physical activity and sedentarism. Therefore, we examined the relationship between all-cause mortality and behavioral patterns among adults in the United States. Data of 17,730 non-institutionalized US civilians aged ≥20 years were extracted from the 2007-2014 National Health and Nutrition Examination Survey. We set the criteria for metabolic equivalents as 600 according to the WHO guideline, and sedentary time as 300 min/day according to the median. The Cox proportional hazards model was adjusted for demographic and lifestyle characteristics. During the 58.54±28.18 months follow-up, all-cause mortality rate was 4% and heart-related and cancer mortality rate was 1%. Participants in the high metabolic equivalents and low sedentary time group had a lower risk of all-cause (hazard ratio = 0.41, 95% confidence interval = 0.34-0.50), cardiovascular (hazard ratio = 0.36; 95% confidence interval = 0.23-0.55), and cancer (hazard ratio = 0.55; 95% confidence interval = 0.37-0.83) mortality, compared to those in the low metabolic equivalents and high sedentary time group. Sufficient physical activity and less sedentary behavior reduce all-cause and cause-specific mortality in adults in the United States, especially cardiovascular mortality among the elderly. Additional nationwide policies to improve behavioral patterns among adults need to be implemented in the United States.

Chemokine (C-C Motif) Ligand 8 and Tubulo-Interstitial Injury in Chronic Kidney Disease.

Kidney fibrosis has been accepted to be a common pathological outcome of chronic kidney disease (CKD). We aimed to examine serum levels and tissue expression of chemokine (C-C motif) ligand 8 (CCL8) in patients with CKD and to investigate their association with kidney fibrosis in CKD model. Serum levels and tissue expression of CCL8 significantly increased with advancing CKD stage, proteinuria level, and pathologic deterioration. In Western blot analysis of primary cultured human tubular epithelial cells after induction of fibrosis with rTGF-ß, CCL8 was upregulated by rTGF-ß treatment and the simultaneous treatment with anti-CCL8 mAb mitigated the rTGF-ß-induced an increase in fibronectin and a decrease E-cadherin and BCL-2 protein levels. The antiapoptotic effect of the anti-CCL8 mAb was also demonstrated by Annexin V/propidium iodide staining assay. In qRT-PCR analysis, mRNA expression levels of the markers for fibrosis and apoptosis showed similar expression patterns to those observed by western blotting. The immunohistochemical analysis revealed CCL8 and fibrosis- and apoptosis-related markers significantly increased in the unilateral ureteral obstruction model, which agrees with our in vitro findings. In conclusion, CCL8 pathway is associated with increased risk of kidney fibrosis and that CCL8 blockade can ameliorate kidney fibrosis and apoptosis.

Analysis of Cancer Patient Decision-Making and Health Service Utilization after Enforcement of the Life-Sustaining Treatment Decision-Making Act in Korea.

PURPOSE: This study aimed to confirm the decision-making patterns for life-sustaining treatment (LST) and analyze medical service utilization changes after enforcement of the Life-Sustaining Treatment Decision-Making Act. MATERIALS AND METHODS: Of 1,237 patients who completed legal forms for life-sustaining treatment (hereafter called the LST form) at three academic hospitals and died at the same institutions, 1,018 cancer patients were included. Medical service utilization and costs were analyzed using claims data. RESULTS: The median time to death from completion of the LST form was three days (range, 0 to 248 days). Of these, 517 people died within two days of completing the document, and 36.1% of all patients prepared the LST form themselves. The frequency of use of the intensive care unit, continuous renal replacement therapy, and mechanical ventilation was significantly higher when the families filled out the form without knowing the patient's intention. In the top 10% of the medical expense groups, the decision-makers for LST were family members rather than patients (28% patients vs. 32% family members who knew and 40% family members who did not know the patient's intention). CONCLUSION: The cancer patient's own decision-making rather than the family's decision was associated with earlier decision-making, less use of some critical treatments (except chemotherapy) and expensive evaluations, and a trend toward lower medical costs.

Awareness of Doctors' Shared Decision-Making in Life-Sustaining Care Decisions.

Purpose: At the end of life, communication is a key factor for good care. However, in clinical practice, it is difficult to adequately discuss end-of-life care. In order to understand and analyze how decision-making related to life-sustaining treatment (LST) is performed, the shared decision-making (SDM) behaviors of physicians were investigated. Methods: A questionnaire was designed after reviewing the literature on attitudes toward SDM or decision-making related to LST. A final item was added after consulting experts. The survey was completed by internal medicine residents and hematologists/medical oncologists who treat terminal cancer patients. Results: In total, 202 respondents completed the questionnaire, and 88.6% said that the decision to continue or end LST is usually a result of SDM since they believed that sufficient explanation is provided to patients and caregivers, patients and caregivers make their own decisions according to their values, and there is sufficient time for patients and caregivers to make a decision. Expected satisfaction with the decision-making process was the highest for caregivers (57.4%), followed by physicians (49.5%) and patients (41.1%). In total, 38.1% of respondents said that SDM was adequately practiced when making decisions related to LST. The most common reason for inadequate SDM was time pressure (89.6%). Conclusion: Although most physicians answered that they practiced SDM when making decisions regarding LST, satisfactory SDM is rarely practiced in the clinical field. A model for the proper implementation of SDM is needed, and additional studies must be conducted to develop an SDM model in collaboration with other academic organizations.

Nephrologists' Perspectives on Decision Making About Life-Sustaining Treatment and Palliative Care at End of Life: A Questionnaire Survey in Korea.

Background: Nephrologists commonly engage in decision making regarding the withholding or withdrawal of dialysis and palliative care in patients at end of life (EoL). However, these issues remain an unsolved dilemma for nephrologists. Objective: To explore nephrologists' perceptions on the decision-making process about withholding or withdrawing dialysis and palliative care in Korea. Design: A nationwide 25-item questionnaire online survey via e-mail. Setting/Subjects: A total of 369 Korean nephrologists completed the survey. Results: The proportions of respondents who stated that withholding or withdrawing dialysis at EoL is ethically appropriate were 87.3% and 86.2%, respectively. A total of 72.4% respondents thought that withdrawal of dialysis in a maintenance dialysis patient is ethically appropriate. Responses regarding patient features that should be considered to withhold or withdraw dialysis were as follows: dialysis intolerance (84.3%), poor performance status (74.8%), patient's active request (47.2%), age (28.7%), very severe dementia (27.1%), and several comorbidities (16.5%). Among those nephrologists who responded to the question about the minimum age, at which dialysis should be withheld or withdrawn, most specified an age between 80 and 90 years (94.3%). Fifty-eight percent of respondents stated that terminally ill dialysis patients should be allowed to use palliative care facilities. In addition, a number of nephrologists thought that adequate palliative care facilities, specific treatment guidelines, enough time to manage patients, financial support, and adequate medical experts are necessary. Conclusions: Korean nephrologists thought that withholding or withdrawing dialysis at EoL is ethically appropriate, even in maintenance dialysis patients. Therefore, consensus guidelines for palliative care after withholding or withdrawal of dialysis are needed.

Proximal Junctional Kyphosis in Degenerative Sagittal Deformity After Under- and Overcorrection of Lumbar Lordosis: Does Overcorrection of Lumbar Lordosis Instigate PJK?

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze proximal junctional kyphosis (PJK) occurrence and surgical outcomes according to degree of lumbar lordosis (LL) correction relative to pelvic incidence (PI). In addition, risk factors of PJK including LL and sagittal vertical axis (SVA) correction were investigated. SUMMARY OF BACKGROUND DATA: PJK is a common complication after adult spinal deformity surgery, and many factors are known to be associated with PJK. However, the effect of degree of LL correction on PJK occurrence is not fully understood. METHODS: Eighty-three degenerative sagittal imbalance patients treated with deformity correction and long instrumented fusion to the sacrum with a minimum follow-up of 2 years were studied. Patients were divided into three groups according to their postoperative LL angle relative to PI using the SRS-Schwab classification: Group A (undercorrection, PI-LL> 10°), Group B (ideal correction, -10°

Strategy for obtaining solid fusion at L5-S1 in adult spinal deformity: risk factor analysis for nonunion at L5-S1.

OBJECTIVE: Maintaining lumbosacral (LS) arthrodesis and global sagittal balance after long fusion to the sacrum remains an important issue in the surgical treatment for adult spinal deformity (ASD). The importance and usefulness of LS fixation have been documented, but the optimal surgical long fusion to the sacrum remains a matter for debate. Therefore, the authors performed a retrospective study to evaluate fusion on CT scans and the risk factors for LS pseudarthrosis (nonunion) after long fusion to the sacrum in ASD. METHODS: The authors performed a retrospective study of 59 patients with lumbar degenerative kyphosis (mean age 69.6 years) who underwent surgical correction, including an interbody fusion of the L5-S1, with a minimum 2-year follow-up. Achievement of LS fusion was evaluated by analyzing 3D-CT scans at 3 months, 6 months, 9 months, 1 year, and 2 years after surgery. Patients were classified into a union group (n = 36) and nonunion group (n = 23). Risk factors for nonunion were analyzed, including patient and surgical factors. RESULTS: The overall fusion rate was 61% (36/59). Regarding radiological factors, optimal sagittal balance at the final follow-up significantly differed between two groups. There were no significant differences in terms of patient factors, and no significant differences with respect to the use of pedicle subtraction osteotomy, the number of fused segments, the proportion of anterior versus posterior interbody fusion, S2 alar iliac fixation versus conventional iliac fixation, or loosening of sacral or iliac screws. However, the proportion of metal cages to polyetheretherketone cages and the proportion of sacropelvic fixation were significantly higher in the union group (p = 0.022 and p < 0.05, respectively). CONCLUSIONS: LS junction fusion is crucial for global sagittal balance, and the use of iliac screws in addition to LS interbody fusion using a metal cage improves the outcomes of long fusion surgery for ASD patients.

Minimally invasive multilevel lateral lumbar interbody fusion with posterior column osteotomy compared with pedicle subtraction osteotomy for adult spinal deformity.

BACKGROUND CONTEXT: Pedicle subtraction osteotomy (PSO) is highly effective as a sagittal correction approach in patients with adult spinal deformity, but relevant issues such as surgical complexity and long-term complications limit its applicability. Recently, minimally invasive techniques have been reported to be useful for surgical treatment of adult spinal deformity; however, few reports have directly compared these techniques with PSO. PURPOSE: The purpose of this study was to evaluate the radiological and clinical efficacies of oblique lateral interbody fusion (OLIF) with posterior column osteotomy (PCO) using stiff rods (6.35-mm cobalt chrome [CoCr]). STUDY DESIGN: Retrospective comparative study. PATIENT SAMPLE: One-hundred six patients (average age 71.3 years) diagnosed with adult spinal deformity presenting with sagittal imbalance for whom follow-up of over 2 years after sagittal correction (between 2013 and 2017) was available. OUTCOME MEASURES: Description and analysis of X-ray, computed tomography scans, operative time, estimated blood loss, and clinical outcomes (Oswestry Disability Index [ODI] and Visual Analog Scale [VAS]). METHODS: A comparative analysis was performed evaluating spinopelvic parameters and clinical outcomes including the ODI, VAS, and complications in patients who underwent PSO (PSO group; n=65) or multilevel prepsoas OLIF combined with PCO and open posterior spinal fusion using 6.35-mm CoCr rods (OLIF group; n=41). The authors have no conflicts of interest to disclose. RESULTS: There were no differences in preoperative spinopelvic parameters between the PSO and OLIF groups. Although no differences were observed between the two groups in terms of postoperative SVA (-12.66 mm vs. -16.44 mm), postoperative lumbar lordosis (-71.46° vs. -72.55°), lumbar lordosis correction (77.96° vs. 73.54°), or postoperative pelvic tilt (9.35° vs. 7.17°), the estimated blood loss was significantly lower in the OLIF group (2824 mL vs. 1736 mL, p<.05). No differences were observed in clinical outcomes (ODI, VAS, and clinical complications), proximal junctional kyphosis, and spinopelvic parameters between the two groups 2 years after surgery. However, pseudarthrosis during the follow-up period, including rod fracture, occurred less frequently in the OLIF group compared with that in the PSO group (p<.05). OLIF was performed from the T12-L1 to L5-S1 regions (124 segments), with an average of three segments per patient. The computed tomography scans immediately after surgery showed an average segmental correction of -18° and 12.9% (16 segments) of 124 segments showed a correction angle of >30°. CONCLUSIONS: Multilevel OLIF with PCO using a stiff rod to treat severe sagittal imbalance resulted in similar levels of sagittal balance and lordosis correction as obtained by PSO. Multilevel OLIF with PCO using a stiff rod can be an effective alternative to PSO for patients with severe sagittal imbalance.

Factors That Influence Attitudes Toward End-of-Life Care Among Medical Students: Nationwide Survey for Fourth-Year Korean Medical Students.

BACKGROUND: Positive attitudes for end-of-life (EOL) care along with adequate education are key factors for the provision of quality EOL care. This national study was conducted to identify the factors that influence attitudes toward EOL care on medical students. METHOD: An anonymous survey was designed and administered to fourth-year medical students at all 41 medical schools in Korea. Topics related to EOL care were assessed in classroom teaching, bedside teaching, and feedback experiences during clinical clerkships. Seven questions for self-rated attitudes and affecting factors were analyzed toward EOL care. RESULTS: With a response rate of 49.2%, the median number of topics recognized by the students as having been delivered was 5 of 11 topics in classroom lectures and 1 of 8 topics in clinical experience. Although few (21.2%) participants indicated that they felt ready for EOL care practice, nevertheless, most felt that they should have adequate knowledge of and preparation for clinical competency in EOL care. Several parameters including respondent's demographics and exposure to EOL care topics in classroom and in bedside teaching influenced the responses to all 7 attitude questions. However, having more than 1 bedside experience was the only factor positively affecting all attitudinal measures. CONCLUSIONS: Clinical experience related to EOL care seems to be the utmost priory in fostering positive attitudes and competency among medical students.

Recurrent Hip Dislocation Following Total Hip Arthroplasty: Treatment with Sagittal Spinal Deformity Correction: A Case Report.

CASE: A 63-year-old woman with lumbar degenerative kyphosis who had undergone total hip arthroplasty 34 months previously presented after having multiple episodes of anterior hip dislocation; evaluation also revealed progressive osteoarthritis in the contralateral hip joint. The patient was managed with sagittal correction with pedicle subtraction osteotomy, which resulted in optimal positioning of the acetabular component and an upright posture. The patient had had no additional dislocation events in the involved hip and had reduced pain in the contralateral hip at the time of the 2-year follow-up. CONCLUSION: It is important to evaluate and address preexisting sagittal imbalance before performing total hip arthroplasty. However, for patients with neglected sagittal imbalance resulting in recurrent hip dislocation after total hip arthroplasty, sagittal deformity correction may be beneficial.

Influence of Hydroxyapatite Stick on Pedicle Screw Fixation in Degenerative Lumbar Spine: Biomechanical and Radiologic Study.

STUDY DESIGN: A prospective, within-patient, left-right comparative study. OBJECTIVE: To evaluate the efficacy of hydroxyapatite (HA) stick augmentation method by comparing the insertional torque of the pedicle screw in osteoporotic and nonosteoporotic patients. SUMMARY OF BACKGROUND DATA: Unsatisfactory clinical outcomes after spine surgery in osteoporotic patients are related to pedicle screw loosening or pull-outs. HA, as a bone graft extender, has a possibility to enhance the fixation strength at the bone-screw interface. METHODS: From November 2009 to December 2010, among patients who required bilateral pedicle screw fixation for lumbar spine surgery, 22 patients were enrolled, who recieved unilateral HA stick augmentation and completed intraoperative insertional torque measurement of each pedicle screws. On the basis of preoperative evaluation of bone mineral density, patients with osteoporosis had 2 HA sticks inserted unilaterally, and 1 stick for patients without osteoporosis. Pedicle screw loosening and pull-outs were assessed using 12-month postoperative CT scans and follow-up radiographs. Clinical evaluation was done preoperatively and at 1 year postoperatively, based on Visual Analog Scale score, Oswestry Disability Index, and Short Form-36 Health Survey. RESULTS: Regardless of bone mineral density, the average torque value of all pedicle screws with HA stick insertion (HA stick inserted group) was significantly higher than that of all pedicle screws without HA insertion (control group) (P<0.0001). Same results were seen in the HA stick inserted subgroups and the control subgroups within both of the osteoporosis group (P=0.009) and the nonosteoporosis group (P=0.0004). There was no statistically significant difference of the rate of pedicle screw loosening in between the HA stick inserted group and the control group. Clinical evaluation also showed no statistically significant difference in between patients with loosening and those without. CONCLUSIONS: The enhancement of initial pedicle screw fixation strength in osteoporotic patients can be achieved by HA stick augmentation.

Effect of Drugs Associated With Bleeding Tendency on the Complications and Outcomes of Transforaminal Epidural Steroid Injection.

STUDY DESIGN: This is a retrospective case-control study. OBJECTIVE: To evaluate the influence of medication-related bleeding tendency on the clinical outcomes and complications of transforaminal epidural steroid injection (TFESI). SUMMARY OF BACKGROUND DATA: TFESI may result in serious complications such as epidural hematoma or adhesions in patients with medication-related bleeding tendency. However, little is known about the true relationship between medication-related bleeding tendency and postprocedural complications. METHODS: Retrospective review of the medical records of patients who had TFESI from 2010 to 2014 was done. Commonly used medications such as warfarin, heparin, aspirin, clopidogrel, and Opalmon (limaprost alfadex) were included as medications associated with bleeding tendency. Patients were divided into 3 groups and the treatment outcomes for each group were compared: The first group used medications associated with bleeding tendency, but discontinued them in due time before the procedure (discontinued group). The second group used medications associated with bleeding tendency and continued receiving medication (continuing group). The third group did not use any medications associated with a bleeding tendency (nonmedicated group). RESULTS: Among 2,469 patients, 1,234 were in the discontinued group, 408 patients in the continuing group, and 827 patients in the nonmedicated group. There were no statistically significant differences between groups for the treatment outcomes such as the degree of pain relief, duration of improvement, and complication rates including symptomatic epidural hematoma. Moreover, for the discontinued group and continuing group, the treatment outcomes were compared among patients with same medication, and revealed no differences. CONCLUSIONS: This study demonstrated that continued use of medications associated with bleeding tendency does not increase epidural hematoma or symptomatic exacerbation, and thus should not be considered as a contraindication for TFESI. LEVEL OF EVIDENCE: Level 3.

Anti-adhesive effect of poloxamer-based thermo-sensitive sol-gel in rabbit laminectomy model.

Poloxamer-based thermo-sensitive sol-gel has been developed to reduce the incidence of postoperative scar formation at the laminectomy site. The purpose of this study was to evaluate the anti-adhesive effect of poloxamer based thermo-sensitive sol-gel compared to hyaluronate based solution after laminectomy, using a rabbit model. A thermo-sensitive anti-adhesive with a property of sol-gel transition was manufactured by a physical mixture of Poloxamer188/407, Chitosan and Gelatin. The viscosity in different temperatures was assessed. 72 adult New Zealand rabbits underwent lumbar laminectomy and were randomly divided into experimental (treated with the newly developed agent), positive (treated with hyaluronate based solution), and negative control groups. Each group was subdivided into 1 and 4-week subgroups. Gross and histological evaluations were performed to assess the extent of epidural adhesion. The experimental group showed significantly higher viscosity compared to the positive control group and showed a significant increase of viscosity as the temperature increased. Gross evaluation showed no statistically significant differences between the 1- and 4-week subgroups. However, histologic evaluation showed significant differences both in 1- and 4-week subgroups. Although the 4-week histologic results of the experimental and the positive control subgroups showed no significant difference, both subgroups revealed higher value compared to the negative control subgroup with regard to the ratio of adhesion less than 50 %. The new poloxamer based thermo-sensitive agent showed superior efficacy over the hyaluronate based agent at 1 week postoperatively. At 4 weeks postoperatively, there were no statistically significant differences between the two agents, although both showed efficacy over the sham group.

Effects of intensive low-salt diet education on albuminuria among nondiabetic patients with hypertension treated with olmesartan: a single-blinded randomized, controlled trial.

BACKGROUND AND OBJECTIVES: The antiproteinuric effect of a renin-angiotensin-aldosterone system blockade can be magnified by dietary salt restriction. This study sought to determine the effect of intensive low-salt diet education on BP and urine albumin excretion in nondiabetic patients with hypertension and albuminuria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This study was conducted between March of 2012 and March of 2013 as an open-label, randomized, controlled trial. After a run-in period of 8 weeks, all patients received the angiotensin II receptor blocker olmesartan (40 mg daily). Patients were then divided into two groups. One group was treated for another 8 weeks with angiotensin II receptor blocker plus conventional low-salt diet education, and the other group was treated for 8 weeks with angiotensin II receptor blocker plus intensive low-salt diet education. The final analyses was performed with 245 completed patients. RESULTS: The amount of daily albuminuria was significantly decreased from 0 (566.0 [25.0-5398.6] mg/d) to 8 weeks (282.5 [16.1-4898.5] mg/d; P<0.001). From 8 to 16 weeks, the 24-hour urinary sodium excretion was decreased by 36.0±5.9 mmol/d in the intensive education group and 8.8±4.9 mmol/d in the conventional education group (interaction P<0.001). Patients who completed intensive low-salt diet education exhibited greater decreases in urinary albumin excretion than the control group (change in albuminuria from 8 to 16 weeks, -154.0 versus 0.4 mg/d; P=0.01). Urinary albumin excretion tended to decrease as the 24-hour urinary sodium excretion amount decreased (R=0.32; 95% confidence interval, 0.20 to 0.43; P<0.001). CONCLUSIONS: The 24-hour urinary albumin excretion was decreased more in patients in the intensive low-salt diet education group than patients in the conventional education group. Weekly intensive education on a low-salt diet would be a suitable method for clinical practice.

The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function.

PURPOSE: To identify whether brachioradialis (BR) release during volar plate fixation for a distal radius fracture affects elbow flexion strength and wrist function. METHODS: A total of 42 consecutive patients who were treated by open reduction volar plate fixation for unstable distal radius fractures were enrolled in this study. The BR was not released in 20 of 42 patients (BR preserved group) and was released in 22 patients (BR released group). The primary outcome variable was isokinetic strength and endurance testing of elbow flexion measured by the Cybex isokinetic system 3 months after surgery. Measured at the same time, secondary outcome variables were grip strength, a visual analog scale score for wrist pain, Disabilities of the Arm, Shoulder, and Hand score, and radiographic parameters. We used Mann-Whitney U tests to compare these variables between groups. RESULTS: Neither elbow flexion strength and endurance nor any of the secondary outcome variables differed significantly between groups. CONCLUSIONS: Release of the BR during a volar approach for a distal radius fracture did not adversely affect elbow flexion strength and wrist function. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Learning curve for endoscopic submucosal dissection of gastric neoplasms.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a widely accepted method for the treatment of early gastrointestinal neoplasms. OBJECTIVES: To investigate the learning curve of ESD performed by a single endoscopist focusing on developing the performance of dissection, shortening the procedure time, and preventing complications. PATIENTS AND METHODS: Records of 120 consecutive ESD procedures performed by a single endoscopist with an ESD knife from December 2007 to April 2013 were collected. For analysis of the learning curve, total procedures were divided into four periods, each comprising 30 sequential ESD procedures. Adjusted procedure time (min) was calculated as specimen area [π×long length (mm)×short length (mm)/4]÷procedure time. The parameters assessed were the en-bloc resection rate, complete resection rate, duration and speed of procedure time, and related complications. RESULTS: Procedure times were significantly longer with lesions located at the upper third of the stomach and with the specimen sizes exceeding 1500 mm. There were significant differences in the adjusted overall procedure time from the first to the third quarter (19.9±11.0 vs. 30.3±11.8, P=0.01) and to the fourth quarter (19.9±11.0 vs. 35.8±15.7, P<0.01), and from the second to the third quarter (21.1±8.3 vs. 30.3±11.8, P=0.04) and to the fourth quarter (21.1±8.3 vs. 35.8±15.7, P<0.01). CONCLUSION: ESD for gastric neoplasms can be performed with a steady speed after the experience of 60 ESD procedures with proper clinical outcomes. Further studies with different endoknives will be required for ESD operators as a reference.

What is the minimum clinically important difference in grip strength?

BACKGROUND: Grip strength reflects functional status of the upper extremity and has been used in many of the clinical studies regarding upper extremity disease or fracture. However, the smallest difference in grip strength that a patient would notice as an improvement resulting from treatment (defined as the minimum clinically important difference [MCID]), to our knowledge has not been determined. QUESTIONS/PURPOSES: We asked (1) how 1-year postsurgery grip strength compares with preinjury values; (2) if grip strength correlated with patient's ratings; (3) what the MCID is in the grip strength; and (4) if these values are equivalent to or greater than what can be explained by measurement errors in patients treated for distal radius fracture. METHODS: Fifty patients treated by volar locking plate fixation for a distal radius fracture constituted the study cohort. Grip strengths were measured 1 year after surgery on the injured and uninjured sides using a dynamometer. Grip strengths before injury were estimated using the grip strengths of the uninjured side with consideration of hand dominance. Patients were asked to rate their subjective level of grip strength weakness at 1 year postoperatively. Receiver operator characteristic curve analysis was used to determine MCIDs. Minimal detectable change in grip strength, which is a statistical estimate of the smallest change between two measurement points expected by measurement error or chance alone, also was determined using the formula 1.65 × âˆš2 × standard error of measurement. RESULTS: One year after surgery, grip strength (23 kg; 95% CI, 20-27) was less compared with calculated preinjury values (28 kg; 95% CI, 25-31; p < 0.001). Patients' rating of grip strength and measured grip strength changes correlated well (p = 0.56). MCIDs were 6.5 kg for grip strength and 19.5% for percentage grip strength. The MCID was not less than the minimum detectable change for grip strength (also 6.5 kg). CONCLUSIONS: The MCID of the grip strength was a decrease of 6.5 kg (19.5%). We believe the MCID of grip strength is useful for evaluating effectiveness of new treatments and for determining appropriate sample size in clinical trials of distal radius fractures. LEVEL OF EVIDENCE: Level III diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.