Atypical Resting State Functional Neural Network in Children With Autism Spectrum Disorder: Graph Theory Approach.

Measuring whole brain networks is a promising approach to extract features of autism spectrum disorder (ASD), a brain disorder of widespread regions. Objectives of this study were to evaluate properties of resting-state functional brain networks in children with and without ASD and to evaluate their relation with social impairment severity. Magnetoencephalographic (MEG) data were recorded for 21 children with ASD (7 girls, 60-89 months old) and for 25 typically developing (TD) control children (10 girls, 60-91 months old) in a resting state while gazing at a fixation cross. After signal sources were localized onto the Desikan-Killiany brain atlas, statistical relations between localized activities were found and evaluated in terms of the phase lag index. After brain networks were constructed and after matching with intelligence using a coarsened exact matching algorithm, ASD and TD graph theoretical measures were compared. We measured autism symptoms severity using the Social Responsiveness Scale and investigated its relation with altered small-worldness using linear regression models. Children with ASD were found to have significantly lower small-worldness in the beta band (p = 0.007) than TD children had. Lower small-worldness in the beta band of children with ASD was associated with higher Social Responsiveness Scale total t-scores (p = 0.047). Significant relations were also inferred for the Social Awareness (p = 0.008) and Social Cognition (p = 0.015) sub-scales. Results obtained using graph theory demonstrate a difference between children with and without ASD in MEG-derived resting-state functional brain networks, and the relation of that difference with social impairment. Combining graph theory and MEG might be a promising approach to establish a biological marker for ASD.

Epileptiform discharges relate to altered functional brain networks in autism spectrum disorders.

Many individuals with autism spectrum disorders have comorbid epilepsy. Even in the absence of observable seizures, interictal epileptiform discharges are common in individuals with autism spectrum disorders. However, how these interictal epileptiform discharges are related to autistic symptomatology remains unclear. This study used magnetoencephalography to investigate the relation between interictal epileptiform discharges and altered functional brain networks in children with autism spectrum disorders. Instead of particularly addressing individual brain regions, we specifically examine network properties. For this case-control study, we analysed 70 children with autism spectrum disorders (52 boys, 18 girls, 38-92 months old) and 19 typically developing children (16 boys, 3 girls, 48-88 months old). After assessing the participants' social reciprocity using the Social Responsiveness Scale, we constructed graphs of functional brain networks from frequency band separated task-free magnetoencephalography recordings. Nodes corresponded to Desikan-Killiany atlas-based 68 brain regions. Edges corresponded to phase lag index values between pairs of brain regions. To elucidate the effects of the existence of interictal epileptiform discharges on graph metrics, we matched each of three pairs from three groups (typically developing children, children with autism spectrum disorders who had interictal epileptiform discharges and those who did not) in terms of age and sex. We used a coarsened exact matching algorithm and applied adjusted regression analysis. We also investigated the relation between social reciprocity and the graph metric. Results show that, in children with autism spectrum disorders, the average clustering coefficient in the theta band was significantly higher in children who had interictal epileptiform discharges. Moreover, children with autism spectrum disorders who had no interictal epileptiform discharges had a significantly lower average clustering coefficient in the theta band than typically developing children had. However, the difference between typically developing children and children with autism spectrum disorder who had interictal epileptiform discharges was not significant. Furthermore, the higher average clustering coefficient in the theta band corresponded to severe autistic symptoms in children with autism spectrum disorder who had interictal epileptiform discharges. However, the association was not significant in children with autism spectrum disorders who had no interictal epileptiform discharge. In conclusion, results demonstrate that alteration of functional brain networks in children with autism spectrum disorders depends on the existence of interictal epileptiform discharges. Interictal epileptiform discharges might 'normalize' the deviation of altered brain networks in autism spectrum disorders, increasing the clustering coefficient. However, when the effect exceeds tolerance, it actually exacerbates autistic symptoms.

Different associations between intelligence and social cognition in children with and without autism spectrum disorders.

Autism spectrum disorders (ASD) are characterized by impaired social cognition and communication. In addition to social impairment, individuals with ASD often have intellectual disability. Intelligence is known to influence the phenotypic presentation of ASD. Nevertheless, the relation between intelligence and social reciprocity in people with ASD remains unclear, especially in childhood. To elucidate this relation, we analyzed 56 typically developing children (35 male, 21 female, aged 60-91 months) and 46 children with ASD (35 male, 11 female, aged 60-98 months) from university and affiliated hospitals. Their cognitive function was evaluated using the Kaufman Assessment Battery for Children. Their social cognition was assessed using the Social Responsiveness Scale. We used linear regression models to ascertain whether the associations between intelligence and social cognition of typically developing children and children with ASD are significantly different. Among the children with ASD, scores on the Kaufman Assessment Battery for Children correlated significantly with social cognition, indicating that higher intelligence is associated with better social cognition. For typically developing children, however, no significant correlation was found. One explanation might be that children with ASD fully use general intelligence for successful learning in social cognition, although extensive use of intelligence might not be necessary for TD children. Alternatively, autistic impairment in social cognition can be compensated by intelligence despite a persistent deficit in social cognition. In either case, when using the SRS as a quantitative phenotype measure for ASD, the influence of intelligence must be considered.

Impact of a Novel Oblique-Tip Papillotome for Biliary Cannulation during ERCP: A Nonrandomized Coarsened Exact Matching Study.

BACKGROUND: We developed a novel oblique-tip papillotome (OT-papillotome) to facilitate biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP). This study was performed to evaluate the utility of the OT-papillotome for contrast-guided cannulation (CGC) and wire-guided cannulation (WGC) during ERCP, compared with standard cannulation by WGC using a standard-tip papillotome (ST-papillotome). METHODS: A prospective study was performed at two centers. CGC with the OT-papillotome (OT-CGC group) was performed at Jikei University Hospital, while WGC was done with the OT-papillotome and ST-papillotome (OT-WGC and ST-WGC groups, respectively) at the University of Malaya Medical Centre. The results of the OT-CGC and OT-WGC groups were compared with those of the ST-WGC group after performing coarsened exact matching (CEM) to reduce bias due to nonrandomized and center-based patient allocation. RESULTS: Eighty patients were enrolled in each of the OT-CGC, OT-WGC, and ST-WGC groups. After CEM, the successful biliary cannulation rate was significantly higher in the OT-CGC and OT-WGC groups than in the ST-WGC group, while rescue cannulation was reduced. The mean number of unintended pancreatic access events in the OT-WGC and OT-CGC groups was similar to the ST-WGC group. However, it was significantly lower in the OT-WGC group than in the OT-CGC group. Multivariate analysis revealed that the OT-papillotome was independently associated with less frequent rescue cannulation and a higher successful biliary cannulation rate. CONCLUSIONS: Although use of the OT-papillotome in biliary cannulation did not reduce unintended pancreatic access events or PEP compared to the ST-papillotome, the OT-papillotome increased the successful biliary cannulation rate, while reducing the frequency of rescue cannulation procedures. Combining the OT-papillotome with WGC might be the best cannulation technique for minimizing unintended pancreatic access.

Familial caregivers' experiences with home-visit nursing for persons with dementia who live alone.

AIM: The Japanese Comprehensive Strategy to Accelerate Dementia Measures, known as the New Orange Plan, aims to support people with dementia living in their communities. Home-visit nurses (HVN) are expected to play an important role in this comprehensive support system. In this preliminary study, we explored caregivers' experiences before and after implementation of HVN care for persons with dementia who lived alone. METHODS: This study was a qualitative descriptive design using in-depth interviews with five family caregivers of persons with dementia who lived alone while receiving HVN. Thematic content analysis was undertaken. RESULTS: Before receiving HVN, caregivers experienced anxiety and embarrassment due to the occurrence of dementia symptoms, and they also experienced considerable isolation and anguish after hearing the diagnosis. After initiating HVN, caregivers gained a feeling of security and an alleviation of psychological stress. They also gained a deeper understanding of the disease and appropriate care for dementia patients. Notably, caregivers perceived not only positive changes in themselves, but also in the recipients, such as improvements in symptoms and quality of life. Finally, caregivers realized that people with dementia can live alone if appropriate services are provided. CONCLUSION: HVN can have a positive impact on family caregivers involved in dementia care, as well as on the recipients' psychological status. Overall, the experience of HVN made the family caregivers more positive about home care for their family member with dementia. Although further case studies are needed to make definitive conclusions, we believe that HVN could play a key role in the forthcoming New Orange Plan.

Association Between Magnetoencephalographic Interictal Epileptiform Discharge and Cognitive Function in Young Children With Typical Development and With Autism Spectrum Disorders.

Electroencephalograms of individuals with autism spectrum disorders (ASD) show higher rates of interictal epileptiform discharges (IEDs), which are known to have an inverse association with cognitive function in typically developed (TD) children. Nevertheless, that phenomenon has not been investigated adequately in children with ASD. From university and affiliated hospitals, 163 TD children (84 male, 79 female, aged 32-89 months) and 107 children (85 male, 22 female, aged 36-98 months) with ASD without clinical seizure were recruited. We assessed their cognitive function using the Kaufman Assessment Battery for Children (K-ABC) and recorded 10 min of MEG. Original waveforms were visually inspected. Then a linear regression model was applied to evaluate the association between the IED frequency and level of their cognitive function. Significantly higher rates of IEDs were found in the ASD group than in the TD group. In the TD group, we found significant negative correlation between mental processing scale scores (MPS) and the IED frequency. However, for the ASD group, we found significant positive correlation between MPS scores and the IED frequency. In terms of the achievement scale, correlation was not significant in either group. Although we found a correlative rather than a causal effect, typically developed children with higher IED frequency might better be followed up carefully. Furthermore, for children with ASD without clinical seizure, clinicians might consider IEDs as less harmful than those observed in TD children.

Predictors of potentially harmful behaviour by family caregivers towards patients treated for behavioural and psychological symptoms of dementia in Japan.

BACKGROUND: Potentially harmful behaviour (PHB) by caregivers is detrimental to the physical and psychological well-being of care recipients. In Japan, few studies have investigated caregivers' PHB towards dementia patients. This study examined PHB in family caregivers of dementia patients with behavioural and psychological symptoms of dementia (BPSD) and identified factors related to PHB. METHODS: Following primary consultations at an elderly psychiatric patient department, we enrolled 133 pairs of dementia patients and their family caregivers. We assessed PHB using the Japanese version of the modified Conflict Tactics Scale. We defined the presence of PHB as two or more points (PHB frequency of 'sometimes' or more) on at least one indicator of the modified Conflict Tactics Scale. We investigated the prevalence of PHB in relation to the clinical characteristics of the patients and their family caregivers. We evaluated BPSD using the Neuropsychiatric Inventory and caregiver burden using the eight-item Japanese version of the Zarit Caregiver Burden Interview. RESULTS: Of the family caregivers, 48.9% showed PHB. Multivariate analysis identified the following association with PHB: caregiver's Zarit Caregiver Burden Interview total score (odds ratio [OR], 1.09 per unit increase; 95% confidence interval [95%CI], 1.02-1.16), and Neuropsychiatric Inventory scores for patient irritability (OR, 1.22 per unit increase; 95%CI, 1.06-1.40), appetite/eating disorders (OR, 1.41 per unit increase; 95%CI = 1.08-1.84) and daughters-in-law caregivers (OR, 0.17, 95%CI, 0.05-0.57). CONCLUSIONS: Specific BPSD symptoms could contribute to the expression of PHB. In addition to decreasing caregiver burden, more intensive treatment and care strategies are required to manage individual symptoms.

Effect of preceding home-visit nursing on time to discharge in hospitalization for the treatment of behavioural and psychological symptoms of dementia among patients with limited familial care.

BACKGROUND: During hospitalization for behavioural and psychological symptoms of dementia (BPSD), it is imperative to build a support system for each patient in the community for after they obtain symptom remission. To this end, patients lacking adequate family support are less likely to be discharged to their own homes and need stronger support systems to be established. This study therefore investigated the effects of home-visit nursing before admission on time to home discharge among patients with limited familial care who were hospitalized for treatment of BPSD. METHODS: A single-centre chart review study was conducted on consecutive patients admitted from home between April 2013 and September 2015 for treatment of BPSD and who had lived alone or with a working family member. Time to home discharge was compared between patients who had home-visit nursing before their admission and those who did not. RESULTS: In total, 58 patients were enrolled in the study, of whom 12 had preceding home-visit nursing (PHN group) and 46 did not (non-PHN group). Patients in the PHN group were younger (77.7 ± 4.9 vs. 84.1 ± 6.1 years, P = 0.0011) and had higher Mini-Mental State Examination scores (16.8 ± 7.2 vs 11.8 ± 7.3, P = 0.0287). A multivariate Cox proportional hazard regression analysis adjusted for age and Mini-Mental State Examination scores showed a higher likelihood of discharge to home in the PHN group (hazard ratio: 3.85; 95% confidence interval: 1.27-11.6;, P = 0.017) than in the non-PHN group. CONCLUSION: Home-visit nursing before admission of BPSD patients for treatment could improve the rate of discharge to home among patients with limited familial care after subsequent hospitalization. Home-visit nursing could also enhance collaborative relationships between social and hospital-based care systems, and early implementation could improve the likelihood of vulnerable patient types remaining in their own homes for as long as possible.

Influence of reviewers' clinical backgrounds on interpretation of confocal laser endomicroscopy findings.

BACKGROUND AND STUDY AIMS: Substantial differences in endoscopic strategy for gastric cancer exist between Western and Eastern countries, owing to clinicoepidemiological diversity, including differences in the prevalence of gastric cancer. This international multicenter study involved German and Japanese institutions and aimed to evaluate the influence of reviewers' clinical backgrounds on interpreting probe-based confocal laser endomicroscopy (pCLE) findings for diagnosis of superficial gastric lesions. PATIENTS AND METHODS: 39 reviewers answered questionnaires about their clinical background and then reviewed 30 sets of white light endoscopy (WLE) and pCLE video clips via an online questionnaire. For each set of clips, reviewers were asked to classify lesions as neoplastic or non-neoplastic. RESULTS of video reviews were compared with the final histopathological diagnosis for each lesion. The accuracy of diagnosis based on WLE + pCLE was compared with that based on WLE alone for each aspect of clinical background. RESULTS: The overall accuracy of diagnosis based on WLE + pCLE was higher than that based on WLE alone (73.93 % vs. 65.64 %, P = .0002). Outcomes of expert gastroenterologists were better than those of pathologists (P = .038 for WLE, P = .002 for WLE + pCLE) and outcomes of reviewers at Japanese institutions were better than those of reviewers at German institutions (P = .001 for WLE, P < .001 for WLE + pCLE). CONCLUSIONS: Reviewers from Japanese institutions and expert gastroenterologists performed well in the pCLE interpretation. Substantial experience in conventional endoscopy is important for interpreting pCLE images for the diagnosis of gastric cancer.University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR; www.umin.ac.jp/ctr/index.htm) number UMIN 000013437).

Reduced prefrontal activation during performance of the Iowa Gambling Task in patients with bipolar disorder.

The Iowa Gambling Task (IGT) is a complex decision-making task in which monetary wins and losses guide the development of strategies. The objective of this study was to evaluate hemodynamic responses of patients with bipolar disorder (BD) during performance of the IGT using near-infrared spectroscopy (NIRS). Participants comprised 13 patients and 15 healthy control subjects who were matched for age, sex, handedness, and intelligence quotient. Relative changes in oxygenated and deoxygenated hemoglobin (oxy-Hb and deoxy-Hb) levels in the frontal region were measured using a 46-channel NIRS system. All subjects were evaluated using NIRS during a verbal fluency task (VFT) and the IGT. During performance of the IGT, BD patients showed significantly decreased oxy-Hb levels in the bilateral orbitofrontal cortex (OFC) and left prefrontal cortex (PFC) compared with normal control subjects. However, during the VFT, patients with BD showed no significant changes in oxy-Hb levels compared with control subjects. Changes in oxy-Hb levels in the bilateral OFC and the PFC during the IGT were negatively correlated with total scores on the Hamilton Rating Scale for Depression (HAM-D). Although the IGT was useful for differentiating patients with BP from control subjects, no significant differences in autonomic activity were observed.

Predictors of home discharge among patients hospitalized for behavioural and psychological symptoms of dementia.

BACKGROUND: The Japanese government recently announced the 'Five-Year Plan for Promotion of Measures Against Dementia (Orange Plan)' to promote people with dementia living in their communities. To achieve this, it is imperative that patients hospitalized with behavioural and psychological symptoms of dementia (BPSD) are helped to return to their own homes. The aim of the present study was to identify predictors of home discharge among patients hospitalized for BPSD. METHODS: A single-centre chart review study was conducted on consecutive patients hospitalized from home between April 2006 and March 2011 for the treatment of BPSD. The frequency of discharge back to home was examined in relation to a patient's active behavioural problems and demographics at the time of admission. Diagnoses of dementia were made on the basis of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies. RESULTS: In all, 391 patients were enrolled in the study. Of these patients, 163 (42%) returned home. Multiple logistic regression analysis identified high Mini-Mental State Examination and Nishimura-style senile activities of daily living scores as significant independent predictors of home discharge. In contrast, living alone and manifestation of aggressiveness at the time of admission were negatively associated with home discharge. CONCLUSIONS: Few patients hospitalized for BPSD are discharged home, and this number is affected by a patient's clinical and demographic characteristics at the time of admission. These findings should be considered in designing and implementing optimal management and care strategies for patients with BPSD.

Outcomes of Inpatient Treatment for Behavioral and Psychological Symptoms of Dementia in Alzheimer's Disease Versus Dementia With Lewy Bodies.

OBJECTIVE: Most community-based studies have shown a more malignant clinical course for patients with dementia with Lewy bodies (DLB) than Alzheimer's disease (AD). We examined differences in outcomes between patients with DLB and AD hospitalized for the treatment of behavioral and psychological symptoms of dementia. METHOD: A chart review was conducted of patients with either AD or DLB hospitalized in the acute psychogeriatric ward between January 2008 and December 2011 in Kahoku-City, Ishikawa, Japan. Outcome measures were discharge destinations and time to death. A diagnosis of AD was made according to DSM-5 criteria, whereas a diagnosis of DLB was made according to the Consortium on DLB International Workshop criteria for probable DLB. Pharmacologic treatment was optimized under constant monitoring of patients. Cholinesterase inhibitors and yi-gan san were tried prior to antipsychotics in DLB patients. RESULTS: The study cohort consisted of 224 patients with AD and 106 with DLB. After matching for sociodemographic factors and cognitive and physical function, it was found that antipsychotics were less frequently used during hospitalization in patients with DLB than AD (63% vs 82%, respectively, P < .01), whereas cholinesterase inhibitors (88% vs 43%, P < .001) and yi-gan san (35% vs 20%, P < .05) were more frequently used in patients with DLB. There were no significant differences in discharge destinations between the 2 groups. The 5-year cumulative survival rates were similar in the AD and DLB groups (46.4% vs 45.7%, respectively, P = .6225). CONCLUSIONS: Optimization of pharmacologic treatment during hospitalization could reduce the use of antipsychotics and improve the subsequent clinical course in DLB.

Contrast-enhanced harmonic endoscopic ultrasonography in the differential diagnosis of gallbladder wall thickening.

BACKGROUND AND AIMS: Differentiation of gallbladder (GB) carcinoma from benign GB wall thickening is challenging. The recent introduction of second-generation ultrasonic contrast agents has made contrast harmonic imaging with EUS possible. The aim of our study was to evaluate the utility of contrast-enhanced harmonic EUS (CH-EUS) for the differential diagnosis of GB wall thickening. METHODS: Thirty-six consecutive patients with GB wall thickening imaged by CH-EUS and then underwent surgery were enrolled in this study. After the lesions were observed with conventional harmonic EUS (H-EUS), CH-EUS was performed with intravenous injection of 0.015 ml/kg of Sonazoid. Three reviewers with various levels of experience of EUS (Reviewer A: experienced endosonographer, B: EUS trainee, C: experienced gastroenterologist with expertise in transabdominal ultrasound but no EUS experience) were blinded to findings of recorded video of H-EUS and CH-EUS. The diagnostic accuracy of H-EUS and CH-EUS for malignant GB wall thickening was compared. RESULTS: Final diagnoses based on surgical histology were GB carcinoma in 16, cholecystitis in 11, adenomyomatosis in 6 and cholesterolosis in 3. Overall sensitivity, specificity and accuracy for diagnosing malignant GB wall thickening of H-EUS and CH-EUS were 83.3 versus 89.6, 65 versus 98% (p < 0.001) and 73.1 versus 94.4% (p < 0.001). The inter-observer agreement for H-EUS was moderate (κ = 0.51), whereas that for CH-EUS was substantial (κ = 0.77). The inhomogeneous enhanced pattern on CH-EUS was a strong predictive factor of malignant GB wall thickening. CONCLUSION: CH-EUS has the potential to improve the preoperative diagnostic accuracy and inter-observer agreement in the differential diagnosis of GB wall thickening.

Use of transoral endoscopy for pharyngeal examination: cross-sectional analysis.

BACKGROUND AND AIM: Transoral endoscopy with narrow band imaging (NBI) is useful for identifying early-stage head and neck cancer. However, the screening capability of transoral upper gastrointestinal endoscopy has not yet been systematically evaluated. We evaluated the usefulness of transoral upper gastrointestinal endoscopy for pharyngeal examination. METHODS: This cross-sectional study evaluated 480 patients. All endoscopic pharyngeal examinations with NBI were carried out in accordance with prescribed procedures, consisting of 10 images each and all images were assessed by a blinded reviewer. We examined the association between the diagnostic usefulness of pharyngeal examination and other factors. RESULTS: Median subject age was 64 years (range 22-90 years), and 64% were male. Almost all patients (98%) had an Eastern Cooperative Oncology Group Performance Status of 0 or 1.Butylscopolamine bromide was given to 382 patients (80%), and a sedative was given to 460 (96%) patients. Median observation time was 74 s (range, 16-362 s), resulting in a mean of 9.0 usable images per patient. However, photographs of the right and left pyriform sinuses were consistently poor. Ordered logistic regression analysis showed that quality images were positively correlated with increased patient age. CONCLUSIONS: Transoral endoscopic examination was possible in most patients for screening of the head and neck. However, results were poor in the pyriform sinuses, indicating that additional improvements of examination methods and instruments are needed to enhance screening accuracy.

Propensity score matched lesion-based comparison of long-term clinical and angiographic outcomes after placement of sirolimus (Cypher Bx Velocity) and paclitaxel (TAXUS Express)-eluting stents for de novo native coronary stenosis.

Long-term clinical and angiographic outcomes after sirolimus (SES: Cypher Bx Velocity) and paclitaxel (PES: TAXUS Express)-eluting stent implantation were firstly compared in Japan. During PES-available period from May 2007 to February 2009, 1068 nonrandomized consecutive de novo native coronary lesions treated either with a PES (682 lesions) or SES were enrolled in this study, and a retrospective examination was conducted in April 2013. During that interval, the use ratio of drug-eluting stent (i.e. SES plus PES) was 94.2 %. By adjusting the baselines with a propensity score matching analysis produced 383 lesions in each arm, the incidence of the clinical endpoint (1500-day cardiac death, nonfatal recurrent myocardial infarction, and definite stent thrombosis) after placement of SES (2.1 %; mean follow-up, 1400 ± 290 days) was not significantly different from that in the PES group (2.6 %; 1394 ± 325 days, p = 0.637). SES did not relate to the clinical endpoint (hazard ratio 1.04; 95 % CI 0.29-3.76; p = 0.949). In the baseline-adjusted angiographic followed up lesions (n = 234 in each arm), the incidence of binary restenosis (percent diameter stenosis [%DS] >50 %) in the SES group (12.0 %; mean follow-up, 477 ± 281 days) was not significantly different from that in the PES group (14.5 %; 497 ± 341 days, p = 0.431). SES did not relate to binary restenosis (Odds ratio 0.73; 95 % CI 0.40-1.32; p = 0.295). In conclusion, the present propensity score matched lesion-based analysis firstly showed the statistical equivalent long-term clinical and angiographic outcomes after either SES or PES placement for de novo native coronary lesion in Japanese patients in a daily practice environment.

A double-blind, block-randomized, placebo-controlled trial to identify the chemical assistance effect of mesna submucosal injection for gastric endoscopic submucosal dissection.

BACKGROUND: Previous animal studies and a pilot clinical trial demonstrated that submucosal injection of a thiol compound called mesna could chemically soften connective tissues and thus facilitate endoscopic submucosal dissection (ESD). OBJECTIVE: To evaluate whether mesna injection could reduce procedural times for gastric ESD. DESIGN: Double-blind, block-randomized, controlled trial. SETTING: University hospital. PATIENTS: A total of 101 patients with superficial gastric cancer indicated for ESD were enrolled and randomly assigned to either the mesna or control (saline solution) group. INTERVENTION: Traditional ESD was performed with a single bolus injection of mesna or saline solution. MAIN OUTCOME MEASUREMENTS: Time for submucosal dissection (TSD). RESULTS: En bloc resection was achieved for all lesions in the mesna group (53/53) and 51 of 52 lesions (98.08%) in the control group. TSD was not statistically different between the groups (18.62 ± 13.9 [mean ± SD] minutes for the mesna group and 24.58 ± 24.55 [mean ± SD] minutes for the control group; P = .128), and there were fewer time-consuming cases (times over 30 minutes) in the mesna group compared with controls (7/53 vs 15/52; P = .049). Multivariate regression analysis demonstrated that use of mesna, specimen size, and the presence of fibrous scars were significantly correlated with TSD (P < .05). LIMITATIONS: Single-center study. CONCLUSION: TSD was not significantly different between the mesna and control injection groups, but multivariate analysis indicated that mesna injection reduced procedural challenges associated with the submucosal dissection. ( CLINICAL TRIAL REGISTRATION NUMBER: UMIN000003786.).

Comparison of long-term clinical and 1-year angiographic outcomes after primary stenting (-12 hours) and late reperfusion (12 hours-) using sirolimus-eluting stents for ST-segment elevated myocardial infarctions: a propensity score matching analysis.

OBJECTIVE: We compared the long-term clinical and 1-year angiographic outcomes in ST-segment elevation myocardial infarction (STEMI) patients who presented between 12 to 48 hours after symptom onset and underwent emergent procedures (late reperfusion) using sirolimus-eluting stents (SES; Cypher Bx Velocity) with those of primary stenting patients who presented within 12 hours. METHODS: The study design was a retrospective, nonrandomized single-center study in which the investigations were conducted in October 2012 following the enrollment of consecutive STEMI patients treated with late reperfusion (n=75) and primary stenting using SES (n=386) between September 2004 and May 2007. The incidence of the primary end points (cardiac death, nonfatal recurrent MI and definite stent thrombosis) after late reperfusion (6.7%; mean follow-up, 2,176±742 days) was not significantly different from that observed after primary stenting (8.5%; 2,237±722 days) (p=0.59). The incidence of the secondary end point (binary in-stent restenosis: % diameter stenosis greater than 50% on secondary angiography at approximately one year) after late reperfusion (11.1%, n=54) was not statistically different from that observed after primary stenting (8.0%, n=276) (p=0.45). Using a propensity score matching analysis, the incidences of the primary (6.7%, n=75) and secondary (11.3%, n=53) end points after late reperfusion were not found to be significantly different from those observed after primary stenting (8.0% and 9.4%) (p=0.75 and 0.75, respectively). CONCLUSION: The present small study showed the long-term clinical and 1-year angiographic outcomes after late reperfusion using SES for STEMI patients in emergent procedures in daily practice to be statistically equivalent to those observed after primary stenting using SES for STEMI patients.

Propensity-matched lesion-based comparison of midterm outcomes of TAXUS Express and TAXUS Liberté stents for de novo native coronary stenosis.

BACKGROUND: We examined the implication of the revised platform of TAXUS Liberté (TAXUS-Lib; Boston Scientific, Natick, MA, USA) from TAXUS Express (TAXUS-Exp; Boston Scientific) stents, after stent placements in a daily practice environment, on midterm clinical and angiographic outcomes. METHODS AND RESULTS: By adjusting historically different baselines with propensity score matching analysis in 1358 de novo native coronary stenoses, the incidence of the clinical safety endpoint (700-day cardiac death, nonfatal recurrent myocardial infarction, and definite stent thrombosis) after placement of TAXUS-Lib (0.60%; mean follow-up, 683±64 days) was not significantly different from that in the TAXUS-Exp group (1.20%; 677±96 days, p=0.182). Cardiac dysfunction (ejection fraction of left ventricle less than 40%) was the predictor of primary endpoint [odds ratio (OR), 17.8; 95% CI, 4.39-71.9; p<0.001]. In the baseline-adjusted angiographic followed-up lesions (n=443 in each arm), the incidence of secondary endpoint [binary in-stent restenosis: percent diameter stenosis (%DS) >50% at the follow-up angiography] in the TAXUS-Lib group (11.3%) was not significantly different from that in the TAXUS-Exp group (13.5%, p=0.368). TAXUS-Exp was not the predictor of secondary endpoint (OR, 1.20; 95% CI, 0.77-1.85; p=0.424). CONCLUSIONS: The midterm clinical and angiographic outcomes after placement of the new TAXUS-Lib stent for de novo coronary stenosis in a daily practice environment were statistically equivalent compared to the former TAXUS-Exp.

Predictors of time to discharge in patients hospitalized for behavioral and psychological symptoms of dementia.

BACKGROUND/AIMS: In Japan, more than 50,000 patients with dementia are housed in psychiatric facilities, a trend precipitated by prolonged hospitalizations. This study aimed to determine predictors for the time to discharge in patients hospitalized for behavioral and psychological symptoms of dementia (BPSD). METHODS: Medical charts of patients admitted to an acute psychogeriatric ward for treatment of BPSD were reviewed. Cox's proportional hazards model was used to evaluate relationships between active behavioral problems and/or demographics at the time of admission, and the time until favorable discharge (FD), defined as discharge to the patient's own home or a care facility. RESULTS: For the 402 study patients included in this study, median time to FD was 101 days. In addition to family and residential factors, multivariate analysis identified higher Mini-Mental State Examination scores as independent clinical predictors for a shorter hospital stay, whereas male gender and combative behavior as the primary reason for hospital admission were predictors for a longer hospital stay. CONCLUSION: Clinical characteristics can be predictive of the time to discharge for patients with BPSD. Earlier interventions and enhanced care strategies may be needed for patients with a lower likelihood of FD.