Prediction of Walking Independence in Older Women with Vertebral Compression Fracture Using Phase Angle: A Preliminary Study Using Propensity Score.

Objectives: This study aimed to clarify whether phase angle can be a predictor of walking independence in older women with vertebral compression fractures (VCFs) and to determine a clinically usable cutoff value. Methods: We retrospectively assessed data of older women (n=59; median age, 83.0 years) with VCFs. Propensity score-matching and logistic regression were performed to examine the association between phase angle at admission and walking independence at discharge. The cutoff value for the phase angle at admission for predicting walking independence was calculated based on the receiver operating characteristic curve. Results: Thirty-one patients (52.5%) could walk independently at discharge. Thirty patients were extracted from the independent and non-independent groups according to the propensity score. After propensity score matching, there was no significant difference between the groups for age, medical history, knee extension strength, skeletal muscle mass index, mini nutritional assessment-short form score, or revised Hasegawa's dementia scale score. However, the phase angle of the independent group was significantly higher than that of the non-independent group (P<0.05). Logistic regression revealed that phase angle at admission was significantly associated with walking independence at discharge (odds ratio, 12.2; 95% confidence interval, 2.1-72.0; P<0.01). The area under the receiver operating characteristic curve was 0.868, and the calculated phase angle cutoff value was 3.55°. Conclusions: This study revealed that the phase angle can predict walking independence in older women with VCFs. The cutoff values for women calculated in this study can be used as a simple and objective predictive index of walking independence.

Balance Function Required for Bathing Independence in Patients with Stroke and Hip Fracture.

Objectives: Little attention has been paid to the relationship between balance function and bathing independence. This research aimed to determine the degree of balance function needed by patients with stroke and patients with hip fracture (hereinafter referred to as patients with stroke and hip fracture) to bathe independently. Methods: Retrospective data analysis was performed on 59 patients with hip fracture and 201 patients with stroke. Logistic regression was performed to determine whether bathing independence was associated with the Berg Balance Scale (BBS) in patients with stroke and hip fracture. A receiver operating characteristic curve was generated to calculate cutoff values. Results: The BBS was significantly associated with bathing independence in patients with stroke and hip fracture. The calculated BBS cutoff value was 48 points for those with stroke (sensitivity, 84.7%; specificity, 79.1%) and 43 points for those with hip fracture (sensitivity, 81.3%; specificity, 77.8%). Conclusions: Balance function was independently associated with bathing independence. The level of balance function required for bathing independence may be lower for patients with hip fracture than for those with stroke. This could be a simple and useful indicator for rehabilitation professionals to interpret BBS results when conducting bathing interventions.

Age-stroke related dysfunction interaction associated with home discharge of stroke inpatients in the rehabilitation ward.

The purpose of this study was to investigate whether interactions exist among cognitive and physical functions and activities of daily living (ADL) associated with home discharge of stroke patients in the rehabilitation ward. The subjects were 231 patients with a first stroke. Age, gender, affected side, the stroke impairment assessment set, ADL and discharge destination were collected from the medical record. Using a decision tree, a combination of variables that might have an interaction effect associated with home discharge was extracted. The existence of an interaction between the extracted variables was confirmed by logistic regression analysis. A combination of total score of the stroke impairment assessment set (≤27 points) and age (>76.5 years) at admission was extracted from the decision tree. As a result of the logistic regression analysis, this interaction term was significantly associated with home discharge. The findings of the present study suggest that there is an interaction between age and stroke-related dysfunction related to home discharge. Stroke patients aged over 76.5 years with the stroke impairment assessment set score of 27 or less at admission to the rehabilitation ward may need rehabilitation program considering the difficulty of home discharge.

Cutoff Value for a Nutritional Indicator Related to Gait Independence in Elderly Fracture Patients: A Preliminary Study.

OBJECTIVE: Previous studies have reported the relationship between nutritional status and gait independence in elderly fracture patients. However, the degree to which nutritional indicators are related to gait independence is unclear. The purpose of this study is to calculate a cutoff value for a nutritional indicator related to gait independence in patients with hip and vertebral compression fractures. METHOD: This study included 69 patients (33 hip fracture, 36 vertebral compression fracture) who underwent rehabilitation at a convalescent rehabilitation ward. The relationships between nutritional indexes (Mini-Nutritional Assessment-Short Form [MNAⓇ-SF] and skeletal muscle mass index [SMI] ) at admission and gait independence at discharge were analyzed using logistic regression. In addition, receiver operating characteristic analysis was performed to calculate a cutoff value that predicts gait independence. RESULTS: Among the nutritional indicators used in this study, only MNAⓇ-SF was significantly able to predict gait independence at discharge, and this association was maintained, even after adjustment for confounders. The calculated MNAⓇ-SF cutoff values were 5.5 (sensitivity 100%, specificity 46.3%) and 7.5 points (sensitivity 67.9%, specificity 78.0%). CONCLUSION: This study suggests that MNAⓇ-SF may be an index for predicting gait independence in patients with hip or vertebral compression fractures in the convalescent rehabilitation ward. The cutoff values calculated in this study were simple and useful index for physical therapists to interpret the results of MNAⓇ-SF.

Normalizing hyperactivity of the Gunn rat with bilirubin-induced neurological disorders via ketanserin.

BACKGROUND: Severe neonatal hyperbilirubinemia has been known to cause the clinical syndrome of kernicterus and a milder one the syndrome of bilirubin-induced neurologic dysfunction (BIND). BIND clinically manifests itself after the neonatal period as developmental delay, cognitive impairment, and related behavioral and psychiatric disorders. The complete picture of BIND is not clear. METHODS: The Gunn rat is a mutant strain of the Wistar rat with the BIND phenotype, and it demonstrates abnormal behavior. We investigated serotonergic dysfunction in Gunn rats by pharmacological analyses and ex vivo neurochemical analyses. RESULTS: Ketanserin, the 5-HT2AR antagonist, normalizes hyperlocomotion of Gunn rats. Both serotonin and its metabolites in the frontal cortex of Gunn rats were higher in concentrations than in control Wistar rats. The 5-HT2AR mRNA expression was downregulated without alteration of the protein abundance in the Gunn rat frontal cortex. The TPH2 protein level in the Gunn rat raphe region was significantly higher than that in the Wistar rat. CONCLUSIONS: It would be of value to be able to postulate that a therapeutic strategy for BIND disorders would be the restoration of brain regions affected by the serotonergic dysfunction to normal operation to prevent before or to normalize after onset of BIND manifestations. IMPACT: We demonstrated serotonergic dysregulation underlying hyperlocomotion in Gunn rats. This finding suggests that a therapeutic strategy for bilirubin-induced neurologic dysfunction (BIND) would be the restoration of brain regions affected by the serotonergic dysfunction to normal operation to prevent before or to normalize after the onset of the BIND manifestations. Ketanserin normalizes hyperlocomotion of Gunn rats. To our knowledge, this is the first study to demonstrate a hyperlocomotion link to serotonergic dysregulation in Gunn rats.

Improvement in both severe obsessive-compulsive disorder and refractory tardive dystonia following electroconvulsive therapy: A case report.

Background: Obsessive-compulsive disorder (OCD) is often resistant to treatment and may be complicated by tardive dystonia (TDt) with the use of neuroleptics. Furthermore, patients with TDt often have an inadequate response to pharmacotherapy. Although electroconvulsive therapy (ECT) is considered a common treatment option for both TDt and OCD, its efficacy has not been well established for either condition. Case Presentation: Our case was a 37-year-old Japanese woman who showed improvement in both refractory TDt and severe OCD following ECT. A total of 12 ECT sessions resulted in an improvement in both diseases. To the best of our knowledge, this is the first report of a case in which ECT was effective for both TDt and OCD. Conclusion: Our report highlights the following two points: when TDt is associated with severe OCD, and the effect of pharmacotherapy is inadequate, ECT may be considered as a treatment option; given the common mechanism of frontal cortex-basal dysfunction reported in both dystonia and OCD, ECT may have an effect on this pathway.

Impact of Sensory Impairment on Improvement of Upper-limb Function in Patients under 75 Years of Age with Subacute Stroke: A Preliminary Study.

OBJECTIVES: The aim of this study was to investigate whether an interaction exists between sensory impairment and age with respect to the recovery of upper-limb function in patients with subacute stroke. METHODS: This retrospective observational study included 83 patients recovering from subacute stroke in a rehabilitation hospital ward. The recovery of upper-limb function in four groups classified by age and sensory impairment were compared using analysis of covariance. Furthermore, multiple regression analysis was performed with recovery of upper-limb function as the dependent variable and with binarized sensory impairment and binarized age and their interaction term as the independent variables. RESULTS: The estimated marginal means of upper-limb recovery were significantly higher in the non-late elderly (≤74 years) without sensory impairment group than in the other three groups. No significant differences were observed among the following three groups: the non-late elderly with sensory impairment, the late elderly (≥75 years) without sensory impairment, and the late elderly with sensory impairment. In multiple regression analysis, the interaction term between sensory impairment and age was significantly associated with improvement in upper-limb function (ß=0.16, P <0.05). Age alone was significant, but sensory impairment alone was not significant. CONCLUSIONS: Sensory impairment in patients with subacute stroke affects the recovery of upper-limb function as a result of age interactions.

Magnetic Resonance Spectroscopy in the Ventral Tegmental Area Distinguishes Responders to Suvorexant Prior to Treatment: A 4-Week Prospective Cohort Study.

Background: The ventral tegmental area (VTA; a dopaminergic nucleus) plays an important role in the sleep-wake regulation system including orexin system. In addition to neuronal activity, there is increasing evidence for an important role of glial cells (i.e., astrocytes and microglia) in these systems. The present study examined the utility of magnetic resonance spectroscopy (MRS) for detecting neural and/or glial changes in the VTA to distinguish responders from non-responders before treatment with the orexin receptor antagonist suvorexant. Methods: A total of 50 patients were screened and 9 patients were excluded. The remaining 41 patients with insomnia who have or not a psychiatric disease who were expected to receive suvorexant treatment were included in this study. We compared MRS signals in the VTA between responders to suvorexant and non-responders before suvorexant use. Based on previous reports, suvorexant responders were defined as patients who improved ≥3 points on the Pittsburgh Sleep Quality Index after 4 weeks of suvorexant use. MRS data included choline (reflects non-specific cell membrane breakdown, including of glial cells) and N-acetylaspartate (a decrease reflects neuronal degeneration). Results: Among 41 examined patients, 20 patients responded to suvorexant and 21 patients did not. By MRS, the choline/creatine and phosphorylcreatine ratio in the VTA was significantly high in non-responders compared with responders (p = 0.039) before suvorexant treatment. There was no difference in the N-acetylaspartate/creatine and phosphorylcreatine ratio (p = 0.297) between the two groups. Conclusions: Changes in glial viability in the VTA might be used to distinguish responders to suvorexant from non-responders before starting treatment. These findings may help with more appropriate selection of patients for suvorexant treatment in clinical practice. Further, we provide novel possible evidence for a relationship between glial changes in the VTA and the orexin system, which may aid in the development of new hypnotics focusing on the VTA and/or glial cells.

Psychosis in a primary hyperparathyroidism patient with mild hypercalcemia: A case report.

INTRODUCTION: Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia and an elevated level of serum parathyroid hormone (PTH). PHPT presents with a complex set of renal, skeletal, and neuropsychological symptoms. Parathyroidectomy (PTX) is a radical treatment that is recommended for all physically symptomatic patients with PHPT. However, psychiatric symptoms are not considered as an indication for surgery. There remains an important issue from the view of perioperative management of whether PTX should be performed with the presence of uncontrolled psychiatric symptoms or deferred until severe psychiatric symptoms have been controlled. We report a case of mild hypercalcemia that caused severe psychosis in PHPT, which improved dramatically following PTX and resulted in successful postoperative management. PATIENT CONCERN: Our patient was a 68-year-old Japanese woman. She was diagnosed with PHPT, which was triggered by mild hypercalcemia. She was due to receive an operation for osteoporosis and kidney stones. She had severe psychosis, despite medication. Blood examinations revealed mild hypercalcemia (10.4 mg/dL, 8.8-10.1 mg/dL) and elevated serum levels of intact PTH (184.0 pg/mL, 10-65 pg/mL). DIAGNOSIS: She was diagnosed with severe psychosis caused by mild hypercalcemia in PHPT. INTERVENTIONS: Although she was treated with 37.5 mg quetiapine and 2 mg risperidone daily, she was excessively sedated and rejected oral treatment. Therefore, we decided to perform the operation. OUTCOMES: Immediately following surgery, serum levels of calcium, and intact PTH were normalized. Her psychotic symptoms ceased completely 5 days after surgery. CONCLUSION: We emphasize that PHPT presents with various severe psychiatric symptoms, even in mild hypercalcemia. Psychiatric symptoms may be the only salient symptoms in PHPT, and thus clinicians should suspect PHPT in patients with psychiatric symptoms and mild hypercalcemia. Furthermore, PTX is recommended for PHPT-even in the presence of severe uncontrolled psychiatric symptoms, which carries risks for postoperative management-because psychiatric symptoms are expected to improve and good postoperative management is possible.

Prompt improvement of difficulty with sleep initiation and waking up in the morning and daytime somnolence by combination therapy of suvorexant and ramelteon in delayed sleep-wake phase disorder: a case series of three patients.

Patients with delayed sleep-wake phase disorder (DSWPD) suffer from difficulties in sleep initiation at night, difficulties in waking up at the socially required time, and daytime somnolence. About half of the patients resist conventional light therapy and melatonin therapy. Therapy using hypnotics is not recommended due to its adverse effects. Recently, suvorexant, an orexin receptor antagonist, has become available for clinical use. The drug is relatively safer than traditional hypnotics such as benzodiazepines. We report three DSWPD patients who were successfully treated by the combination therapy of suvorexant and ramelteon. The first case was a 19-year-old woman who was experiencing difficulties in sleep initiation, difficulty in waking up in the morning, and daytime somnolence. She showed a prompt response to the combination therapy of suvorexant and ramelteon. Her sleep phase advanced, and her daytime somnolence reduced. The second and third cases were 21-year-old and 17-year-old men, respectively, who also showed significant sleep phase advances. Although case 2 was resistant to ramelteon treatment, his sleep phase advanced after suvorexant started. His difficulty in falling asleep and his habit of daytime napping disappeared after the combination therapy of suvorexant and ramelteon was started. Case 3 also showed a prompt response. His difficulties in falling asleep and waking up in the morning were ameliorated immediately after suvorexant with ramelteon was started. No obvious side effects were observed. Therapy using the combination therapy of suvorexant and ramelteon might be a reasonable option for DSWPD patients.

Interactions of Cognitive and Physical Functions Associated with Toilet Independence in Stroke Patients.

OBJECTIVES: The purpose of this study was to clarify the interaction among cognitive and physical functions associated with toilet independence in stroke patients. MATERIALS AND METHODS: We retrospectively examined 125 stroke patients. We performed decision tree analysis to detect the interaction associated with toilet independent using assessment of motor function on the affected side, muscle strength on unaffected side, trunk function, neglect, motivation, and cognitive function. The interactions detected via decision tree confirmed the existence and influence using logistic regression. RESULTS: The verticality test of the Stroke Impairment Assessment Set (3 or ≤2 points) was selected at the first level, and the Revised Hasegawa's dementia scale (≥19 or ≤18 points) and age (≥70 or ≤69 y) were selected at the second level of decision tree. Interaction terms created by these factors were significantly associated with toilet independence after adjusting for the independent influence of each factor using logistic regression. CONCLUSIONS: Our results show an interaction of trunk and cognitive functions or trunk function and age associated with toilet independence. The probability of toilet independence dramatically changes if two factors of each interaction were satisfied in stroke patients.

Abdominal muscle strength and the recovery of upper extremity function in stroke patients: a study using propensity score matching.

PURPOSE: The purpose of this study was to understand the relationship between abdominal muscle strength and recovery of upper limb function, after adjusting for various confounding factors, such as age, gender, and sensory function. METHODS: We retrospectively analyzed data of 78 sub-acute stroke patients with mild-to-moderate upper limb dysfunction. Participants were divided into two groups, strong and weak, according to the abdominal muscle strength. The improvement of scores on the Simple Test for Evaluating Hand Function was compared between the groups. We employed propensity score matching to adjust for numerous relevant variables, including age, affected side, duration from onset, upper limb function, grip strength, sensory function, visuospatial perception, motivation, and cognitive function at admission. RESULTS: The improvement of scores on the Simple Test for Evaluating Hand Function of the strong group was significantly larger than the weak one, both before and after matching. This trend was noted in the subgroup analysis of participants with moderate dysfunction on admission; however; the trend was not clearly noticeable in participants with mild dysfunction. CONCLUSIONS: Our results suggest that abdominal muscle strength is significantly associated with the recovery of upper limb function in sub-acute stroke patients, especially in those with moderate upper limb dysfunction.Implications for RehabilitationAbdominal muscle strength is associated with the recovery of upper limb function in subacute stroke patients with moderate upper limb dysfunction.Abdominal muscle strength can be used as a predictive factor for the prognosis of upper limb function in stroke patients.

Real-World Preventive Effects of Suvorexant in Intensive Care Delirium: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to examine the effects of suvorexant on delirium prevention in a real-world setting. Previous studies have demonstrated the efficacy of suvorexant for delirium prevention in limited randomized clinical trial settings; however, its effectiveness in everyday clinical settings remains unknown. METHODS: A single-center, retrospective cohort study was conducted in the intensive care unit of an academic hospital. Patients (aged ≥ 3 years) admitted from January 2016 to December 2018 were eligible if they stayed in the intensive care unit for at least 72 hours. Suvorexant was prescribed by the attending physician for insomnia as part of everyday clinical practice. A Cox proportional hazards regression analysis was conducted on delirium-free survival for suvorexant users, adjusting for delirium-related covariates. As part of routine clinical practice, the Confusion Assessment Method for the Intensive Care Unit was used to detect the existence of delirium at least twice daily throughout the intensive care unit stay. RESULTS: There were 699 patients-84 suvorexant users and 615 suvorexant nonusers. Delirium was detected in 214 patients. Delirium prevalence was significantly lower in suvorexant users than in nonusers (17.9% vs 32.4%, respectively; P = .007). Cox regression analysis revealed a significantly lower hazard ratio (0.472; 95% CI, 0.268-0.832; P = .009) of delirium in suvorexant users than in nonusers. Trazodone also had a preventive effect on delirium (hazard ratio 0.345; 95% CI, 0.149-0.802; P = .013). CONCLUSIONS: The present study extends to real-world settings previous findings that suvorexant is effective for delirium prevention.

Low Serum Levels of Fibroblast Growth Factor 2 in Gunn Rats: A Hyperbilirubinemia Animal Model of Schizophrenic Symptoms.

BACKGROUND: Fibroblast Growth Factor (FGF) 2 (also referred to as basic FGF) is a multifunctional growth factor that plays a pivotal role in the pro-survival, pro-migration and prodifferentiation of neurons. METHOD: Because alterations in FGF2 levels are suggested to contribute to the pathogenesis of schizophrenia, we investigated serum levels of FGF2 in the Gunn rat, a hyperbilirubinemia animal model of schizophrenic symptoms. RESULTS: The enzyme-linked immunosorbent assay showed that the serum levels of FGF2 in Gunn rats were 5.09 ± 0.236 pg/mL, while those in the normal strain Wistar rats, serum levels were 11.90 ± 2.142 pg/mL. The serum FGF2 levels in Gunn rats were significantly lower than those in Wistar rats. We also measured serum levels of Unconjugated Bilirubin (UCB) and found a significant negative correlation between UCB and FGF2 in terms of serum levels in all the rats studied. CONCLUSION: Since it is known that FGF2 regulates dopaminergic neurons and have antineuroinflammatory effects, our finding suggests that low FGF2 levels may contribute to the pathogenesis of schizophrenia, in which imbalanced dopamin-ergic signaling and neuroinflammation are supposed to play certain roles.

Functions necessary for gait independence in patients with stroke: A study using decision tree.

BACKGROUND: Little is known about the existence and impact of interactions among multiple impairments to gait independence. The purpose of this study is to reveal the interaction of physical functions and its impact on gait independence in stroke patients. METHODS: This retrospective study included 108 subacute stroke patients. We conducted a decision tree analysis to examine the existence of interactions in relation to gait independence among the gross motor function of lower limb, knee extension strength, sensory function, and trunk function. Further, we confirmed the existence and impact of interaction detected via the decision tree after adjusting for the effects of confounding factors using logistic regression. RESULTS: The knee extension strength and proprioception on the affected side were selected in the first and second level of the decision tree. In addition, the knee extension strength was selected in the third level. The interaction of the knee extension strength and proprioception on the affected side was significantly associated with gait independence, both before and after adjusting for age, visuospatial perception, and cognitive functions. CONCLUSIONS: Our results suggest that the interaction of the knee extension strength and proprioception on the affected side is strongly associated with gait independence in stroke patients.