Prognostic implications of the global leadership initiative on malnutrition criteria as a routine assessment modality for malnutrition in hospitalized patients at a university hospital.

BACKGROUND & AIMS: Few studies have examined the association between mortality and malnutrition diagnosed using the Global Leadership Initiative on Malnutrition (GLIM) criteria for routine nutritional assessment; thus, this association is not well known. We aimed to clarify the association between GLIM-defined malnutrition and mortality in a large population of hospitalized patients. METHODS: In this retrospective cohort study, we enrolled adult patients admitted to Aichi Medical University Hospital between April 2019 and March 2021, who underwent nutritional assessment using the GLIM criteria. In November 2021, we collected the following data from electronic medical records: demographic, clinical, and laboratory data upon admission; nutritional data assessed using GLIM criteria; and data on final patient outcomes. RESULTS: In this study, we included 9372 hospitalized patients who were identified to be at risk by the validated nutritional screening tools (50.6% men, median age 75.0 [67.0-82.0] years, 69.2% patients aged ≥70 years). The number of patients with no, moderate, and severe GLIM-defined malnutrition was 4145 (44.2%), 2799 (29.9%), and 2428 (25.9%), respectively. Kaplan-Meier survival curve analysis showed a significant increase in mortality with worsening nutritional status (log-rank test, P < 0.001). After adjusting for age and sex, multivariable Cox regression analysis revealed that both moderate (Hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.79-2.23, P < 0.001) and severe malnutrition (HR 3.06, 95% CI 2.74-3.40, P < 0.001) were independent risk factors for mortality. Moreover, multivariable analysis showed that four of the five GLIM sub-criteria (except low body mass index) were independently associated with prognosis. CONCLUSION: Malnutrition and its severity, routinely assessed using the GLIM criteria, are associated with high mortality in hospitalized patients at nutritional risk. Further research is needed to evaluate the usefulness of the GLIM sub-criteria, including low body mass index, in these patients.

Evaluation of Adjunctive Ultrasonography for Breast Cancer Detection Among Women Aged 40-49 Years With Varying Breast Density Undergoing Screening Mammography: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Mammography has limited accuracy in breast cancer screening. Ultrasonography, when used in conjunction with mammography screening, is helpful to detect early-stage and invasive cancers for asymptomatic women with dense and nondense breasts. Objective: To evaluate the performance of adjunctive ultrasonography with mammography for breast cancer screening, according to differences in breast density. Design, Setting, and Participants: This study is a secondary analysis of the Japan Strategic Anti-cancer Randomized Trial. Between July 2007 and March 2011, asymptomatic women aged 40 to 49 years were enrolled in Japan. The present study used data from cases enrolled from the screening center in Miyagi prefecture during 2007 to 2020. Participants were randomly assigned in a 1:1 ratio to undergo either mammography with ultrasonography (intervention group) or mammography alone (control group). Data analysis was performed from February to March 2020. Exposures: Ultrasonography adjunctive to mammography for breast cancer screening regardless of breast density. Main Outcomes and Measures: Sensitivity, specificity, recall rates, biopsy rates, and characteristics of screen-detected cancers and interval breast cancers were evaluated between study groups and for each modality according to breast density. Results: A total of 76 119 women were enrolled, and data for 19 213 women (mean [SD] age, 44.5 [2.8] years) from the Miyagi prefecture were analyzed; 9705 were randomized to the intervention group and 9508 were randomized to the control group. A total of 11 390 women (59.3%) had heterogeneously or extremely dense breasts. Among the overall group, 130 cancers were found. Sensitivity was significantly higher in the intervention group than the control group (93.2% [95% CI, 87.4%-99.0%] vs 66.7% [95% CI, 54.4%-78.9%]; P < .001). Similar trends were observed in women with dense breasts (sensitivity in intervention vs control groups, 93.2% [95% CI, 85.7%-100.0%] vs 70.6% [95% CI, 55.3%-85.9%]; P < .001) and nondense breasts (sensitivity in intervention vs control groups, 93.1% [95% CI, 83.9%-102.3%] vs 60.9% [95% CI, 40.9%-80.8%]; P < .001). The rate of interval cancers per 1000 screenings was lower in the intervention group compared with the control group (0.5 cancers [95% CI, 0.1-1.0 cancers] vs 2.0 cancers [95% CI, 1.1-2.9 cancers]; P = .004). Within the intervention group, the rate of invasive cancers detected by ultrasonography alone was significantly higher than that for mammography alone in both dense (82.4% [95% CI, 56.6%-96.2%] vs 41.7% [95% CI, 15.2%-72.3%]; P = .02) and nondense (85.7% [95% CI, 42.1%-99.6%] vs 25.0% [95% CI, 5.5%-57.2%]; P = .02) breasts. However, sensitivity of mammography or ultrasonography alone did not exceed 80% across all breast densities in the 2 groups. Compared with the control group, specificity was significantly lower in the intervention group (91.8% [95% CI, 91.2%-92.3%] vs 86.8% [95% CI, 86.2%-87.5%]; P < .001). Recall rates (13.8% [95% CI, 13.1%-14.5%] vs 8.6% [95% CI, 8.0%-9.1%]; P < .001) and biopsy rates (5.5% [95% CI, 5.1%-6.0%] vs 2.1% [95% CI, 1.8%-2.4%]; P < .001) were significantly higher in the intervention group than the control group. Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, screening mammography alone demonstrated low sensitivity, whereas adjunctive ultrasonography was associated with increased sensitivity. These findings suggest that adjunctive ultrasonography has the potential to improve detection of early-stage and invasive cancers across both dense and nondense breasts. Supplemental ultrasonography should be considered as an appropriate imaging modality for breast cancer screening in asymptomatic women aged 40 to 49 years regardless of breast density. Trial Registration: NIPH Clinical Trial Identifier: UMIN000000757.

Horizontally transmitted parasitoid killing factor shapes insect defense to parasitoids.

Interkingdom competition occurs between hymenopteran parasitoids and insect viruses sharing the same insect hosts. It has been assumed that parasitoid larvae die with the death of the infected host or as result of competition for host resources. Here we describe a gene family, parasitoid killing factor (pkf), that encodes proteins toxic to parasitoids of the Microgastrinae group and determines parasitism success. Pkfs are found in several entomopathogenic DNA virus families and in some lepidopteran genomes. We provide evidence of equivalent and specific toxicity against endoparasites for PKFs found in entomopoxvirus, ascovirus, baculovirus, and Lepidoptera through a mechanism that elicits apoptosis in the cells of susceptible parasitoids. This highlights the evolutionary arms race between parasitoids, viruses, and their insect hosts.

Neuromyelitis Optica Spectrum Disorder Complicated by Posterior Reversible Encephalopathy Syndrome as an Initial Manifestation.

A 25-year-old woman was admitted to our hospital due to tonic convulsion with severe headache after having experienced symptoms of nausea and vomiting for a month. Brain magnetic resonance imaging showed extensive symmetrical lesions in the cortical and subcortical areas of parieto-occipital lobes and basal ganglia, consistent with typical characteristics of posterior reversible encephalopathy syndrome (PRES). Furthermore, some residual lesions in the left side of dorsal medulla oblongata and central area of the cervical spinal cord along with the presence of serum anti-aquaporin-4 antibody yielded the diagnosis of neuromyelitis optica spectrum disorder (NMOSD). We herein discuss the mechanism by which PRES may occur together with NMOSD.

How Should Health Professionals and Policy Makers Respond to Substandard Care of Detained Immigrants?

More people, including children and pregnant women, are being detained for longer periods in a patchwork of over 200 detention centers around the country, most of which are private facilities or county jails. Human Rights Watch has documented systemic medical care failures at these facilities, including incompetent treatment, which is linked to patient deaths. Clinicians working in these facilities face formidable obstacles to providing adequate care, two of which are the Department of Homeland Security's lack of reasonable alternatives to detention and insufficient staffing. Harm caused by these conditions and detention itself should be enough to prompt clinicians to insist that the government enable provision of care consistent with generally accepted standards, including through reducing the detained population.

Two Cases of Primary Sclerosing Cholangitis Overlapping with Autoimmune Hepatitis in Adults.

Overlap syndrome between primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) is extremely rare in Japan. We herein report two adult patients with PSC-AIH overlap syndrome. They were diagnosed with PSC-AIH overlap syndrome based on the findings of endoscopic retrograde cholangiography and liver biopsy, and using the International Autoimmune Hepatitis Group scoring system. In both cases, PSC preceded AIH, and combination therapy with steroid and ursodeoxycholic acid was effective. Because there are few reported cases in Japan, it is important to study more cases to shed light on the clinical and pathological features of PSC-AIH overlap syndrome.

[A case of an anti-SRP myopathy with enlargement of the thymus].

A 54-year-old female was admitted to our hospital because of the Raynaud phenomenon and muscle weakness of the upper limbs. The neurological findings showed somatic and proximal limb weakness. Laboratory studies showed a high serum creatine kinase level. Computerized tomography (CT) revealed enlargement of the thymus. A muscle biopsy showed a small number of degenerating and regenerating fibers but no inflammatory infiltrations. At first, she was initially treated with a three-day course of intravenous methylprednisolone (1 g/day). However, the weakness progressed and the serum creatine kinase level remained high. She was subsequently treated with a combination of tacrolimus (3 mg/day) and prednisolone, but showed no any improvement of the muscle weakness. Following additional treatment with intravenous immunoglobulin, she showed improvement in her muscle weakness. Further, anti-signal recognition particle antibodies were identified after treatment. There have been no previous reports of myopathy with antibodies against the signal recognition particle and enlargement of the thymus, so we herein report the details of this unique case.

[Autoantibodies detected in acetylcholine receptor antibody-negative myasthenia gravis].

Myasthenia gravis (MG) is caused by the failure of neuromuscular transmission mediated by pathogenic autoantibodies (Abs) against the acetylcholine receptor (AChR), muscle-specific receptor tyrosine kinase (MuSK), and unknown autoantibodies. The seropositivity rates for routine AChR binding Ab and MuSK Ab in MG are 85% and a few % for MG patients in Japan, respectively. The autoimmune target in the remaining patients is unknown. In 2001, Hoch et al. reported that a proportion of AChR-Ab-negative MG patients had serum IgG antibodies against MuSK, shedding new light on the pathogenesis of the disease. This idea has been recently supported by many clinical studies, including neonatal myasthenic syndrome and animal model studies. In 2011, autoantibodies against low-density lipoprotein receptor-related protein 4(Lrp4) were identified in Japanese MG patients and, thereafter, have been reported in Germany and the USA. We developed a simple technique termed Gaussia luciferase immunoprecipitation for detecting antibodies to Lrp4. As a result, nine generalized MG patients out of 300 lacking AChR Ab were found to be positive for Lrp4 antibodies. Thymoma was not observed in any of these patients. These antibodies inhibit the binding of Lrp4 to its ligand and are predominantly of the IgG1 subclass. In other reports of Lrp4 ab, Lrp4 ab-positive sera inhibited the agrin-induced aggregation of AChRs in cultured myotubes, suggesting a pathogenic role regarding the dysfunction of the neuromuscular endplate. These results indicate that Lrp4 is the third autoantigen in patients with MG, and anti-Lrp4 autoantibodies may be pathogenic. Further studies including neuromuscular junction biopsy are needed to clarify the pathomechanism of Lrp4 ab-positive MG.

Diurnal variation of human sweet taste recognition thresholds is correlated with plasma leptin levels.

OBJECTIVE: It has recently been proposed that the peripheral taste organ is one of the targets for leptin. In lean mice, leptin selectively suppresses gustatory neural and behavioral responses to sweet compounds without affecting responses to other taste stimuli, whereas obese diabetic db/db mice with defects in leptin receptor lack this leptin suppression on sweet taste. Here, we further examined potential links between leptin and sweet taste in humans. RESEARCH DESIGN AND METHODS: A total of 91 nonobese subjects were used to determine recognition thresholds using a standard stair-case methodology for various taste stimuli. Plasma leptin levels were determined by an enzyme-linked immunosorbent assay at several timepoints during the day under normal and restricted-meal conditions. RESULTS: The recognition thresholds for sweet compounds exhibited a diurnal variation from 0800 to 2200 h that parallels variation for leptin levels, with the lowest thresholds in the morning and the highest thresholds at night. This diurnal variation is sweet-taste selective-it was not observed in thresholds for other taste stimuli (NaCl, citric acid, quinine, and mono-sodium glutamate). The diurnal variation for sweet thresholds in the normal feeding condition (three meals) was independent of meal timing and thereby blood glucose levels. Furthermore, when leptin levels were phase-shifted following imposition of one or two meals per day, the diurnal variation of thresholds for sweet taste shifted in parallel. CONCLUSIONS: This synchronization of diurnal variation in leptin levels and sweet taste recognition thresholds suggests a mechanistic connection between these two variables in humans.

Leptin modulates behavioral responses to sweet substances by influencing peripheral taste structures.

Leptin is a hormone that regulates body weight homeostasis mainly via the hypothalamic functional leptin receptor Ob-Rb. Recently, we proposed that the taste organ is a new peripheral target for leptin. Leptin selectively inhibits mouse taste cell responses to sweet substances and thereby may act as a sweet taste modulator. The present study further investigated leptin action on the taste system by examining expression of Ob-Rb in taste cells and behavioral responses to sweet substances in leptin-deficient ob/ob, and Ob-Rb-deficient db/db mice and their normal litter mates. RT-PCR analysis showed that Ob-Rb was expressed in taste cells in all strains tested. The db/db mice, however, had a RT-PCR product containing an abnormal db insertion that leads to an impaired shorter intracellular domain. In situ hybridization analysis showed that the hybridization signals for normal Ob-Rb mRNA were detected in taste cells in lean and ob/ob mice but not in db/db mice. Two different behavioral tests, one using sweet-bitter mixtures as taste stimuli and the other a conditioned taste aversion paradigm, demonstrated that responses to sucrose and saccharin were significantly decreased after ip injection of leptin in ob/ob and normal littermates, but not in db/db mice. These results suggest that leptin suppresses behavioral responses to sweet substances through its action on Ob-Rb in taste cells. Such taste modulation by leptin may be involved in regulation for food intake.

Conditioned taste aversion learning in leptin-receptor-deficient db/db mice.

The db/db mouse has defective leptin receptors. The defects lead to impairments of leptin regulation of food intake and body weight, and result in the expression of diabetic symptoms such as hyperinsulinemia, hyperglicemia, and extreme obesity. Recent studies have proposed that leptin may also affect memory and learning processes. To examine this possibility, we compared the ability of leptin-receptor-deficient db/db mice and their normal lean litter mates to form and extinguish a conditioned taste aversion (CTA) for saccharin. We used a short-term (10 s) lick test and a long-term (48 h) two bottle preference test for measurement of consumption of test solutions. On the first day after conditioning to avoid saccharin, the db/db mice showed preference scores for saccharin as low, and aversion thresholds for sucrose lower than that of the lean mice. During the extinction test trials beginning from the second up to the 30th day after conditioning, numbers of licks and preference scores for aversive saccharin and sucrose appeared to be larger, and recovered faster to the control levels in db/db mice. These results indicate that db/db mice with leptin-receptor-deficiency may show equal capacity to form CTAs for saccharin, greater generalization from saccharin to sucrose, and a faster rate of extinction. This suggests that disruption of leptin signalling does not inhibit acquisition of CTA learning, but impairs its extinction. This differential contribution of the leptin system on CTA processes may be due to differential distribution of leptin receptors in the CTA-related brain areas.

Leptin and sweet taste.

Leptin, the product of the obese (ob) gene, is a hormone primarily produced in adipose cells, and also at smaller amounts in some other peripheral organs. It regulates food intake, energy expenditure, and body weight. Leptin is thought to promote weight loss, at least in rodents, by suppressing appetite and stimulating metabolism. Mutant mice that lack either leptin or functional leptin receptors, such as ob/ob and db/db mice, are hyperphagic, massively obese, and diabetic. Central hypothalamic targets are mainly responsible for the effects of leptin on food intake and weight loss. However, there are also direct effects on peripheral tissues. Recently, the taste organ was found to be one of the peripheral targets for leptin. The hormone specifically inhibits sweet taste responses in lean mice and not in db/db mice. Thus leptin appears to act as a modulator of sweet taste, provided a functional leptin receptor is expressed by the taste cells. This chapter reviews the genetics and molecular biology of leptin and its receptors, the receptor mechanisms for sweet taste, the modulating action of leptin on taste receptor cells, and the consequences for the regulation of food intake.