The Changes in Broad-spectrum Antimicrobial Consumption during the COVID-19 Pandemic in a Japanese Acute Tertiary-care Hospital: An Interrupted Time-series Analysis.

Objective The novel coronavirus disease 2019 (COVID-19) pandemic has spread worldwide, and hospitals in Japan have been forced to respond to the situation. This study evaluated the broad-spectrum antimicrobial use before and during the COVID-19 pandemic in an acute tertiary-care hospital. Methods This single-center, retrospective study was conducted between January 2019 and June 2021. Patients We reviewed patients treated with three broad-spectrum antipseudomonal agents: carbapenems, tazobactam/piperacillin, and cefepime. Monthly aggregated hospital antimicrobial consumption was measured as days of therapy (DOTs) per 1,000 patient-days, and the monthly incidences of Clostridioides difficile infection (CDI), multidrug-resistant Pseudomonas aeruginosa (MRPA), and carbapenemase-producing Enterobacteriaceae (CPE) were recorded. Results The median monthly carbapenem-DOTs during the pre-pandemic and pandemic era were 8.4 and 8.2 per 1,000 patient-days, respectively. A time-series analysis showed non-significant changes in the level between periods (coefficients: 2.08; 95% confidence interval [CI]: -2.9 to 7.0; p=0.44). No change in the trend of monthly carbapenem-DOTs was observed after intervention. No post-intervention changes in the incidence of MRPA or CPE were observed; however, the trend in the incidence of CDI per 1,000 patient-days significantly differed between the two periods (coefficient: -0.04; 95% CI: -0.07, 0.00; p=0.01), and a downward trend was observed in the monthly CDI incidence during the COVID-19 period. Conclusion The consumption of broad intravenous antimicrobial agents has not changed significantly during the pandemic. We need to maintain the quality of medical care, including antimicrobial stewardship, even in specialized resource-limited facilities during a pandemic.

Comparative effectiveness of early initiation of oral nonsteroidal anti-inflammatory drug and oral acetaminophen therapies on the time to knee replacement in patients with knee osteoarthritis in Japan.

BACKGROUND: Although disease-modifying properties of nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis (OA) have been reported, the effects of NSAIDs on OA progression remain controversial. The purpose of this study was to investigate the effect of early initiation of oral NSAID therapy on the progression of knee OA. METHODS: In this retrospective cohort study, we extracted data of patients newly diagnosed with knee OA between November 2007 and October 2018 from a Japanese claims database. The primary outcome was the time to knee replacement (KR), and the secondary outcome was the time to composite event including joint lavage and debridement, osteotomy, or arthrodesis in addition to KR. Weighted Cox regression analysis with standardized mortality/morbidity ratio (SMR) weight was performed to compare the outcomes between patients prescribed oral NSAID (NSAID group) and those prescribed oral acetaminophen (APAP) (APAP group) early after a diagnosis of knee OA. Propensity scores were calculated using logistic regression conditioned on potential confounding factors, and SMR weights were calculated using the propensity scores. RESULTS: The study population comprised 14,261 patients, who were divided into two groups as follows: 13,994 in the NSAID group and 267 in the APAP group. The mean ages of patients in the NSAID and APAP groups were 56.9 and 56.1 years, respectively. Furthermore, 62.01% and 68.16% patients in the NSAID and APAP groups, respectively, were female. The NSAID group had a reduced risk of KR compared with the APAP group in the analysis using SMR weighting (SMR-weighted hazard ratio, 0.19; 95% confidence interval, 0.05-0.78). While no statistically significant difference was found for the risk of composite event between the two groups (SMR-weighted hazard ratio, 0.56; 95% confidence interval, 0.16-1.91). CONCLUSIONS: The risk of KR in the NSAID group was significantly lower than that in the APAP group after accounting for residual confounding using SMR weighting. This finding suggests that oral NSAID therapy early after the initial diagnosis is associated with a reduced risk of KR in patients with symptomatic knee OA.

Association Between Frontal Lobe Hemodynamics and Neurocognitive Dysfunction in Adults With Moyamoya Disease: Retrospective Cohort Analysis.

BACKGROUND: Adult patients with moyamoya disease (MMD) may present with mild cognitive dysfunction, even those without evidence of conspicuous brain parenchymal damage. This cognitive dysfunction might be caused by local frontal lobe ischemia. OBJECTIVE: To explore the relationship between frontal lobe hemodynamic insufficiency and cognitive dysfunction in patients with MMD. METHODS: Thirty adult patients with MMD without conspicuous brain parenchymal damage were retrospectively examined. Patients with MMD with frontal lobe intracerebral steal phenomenon on single photon emission computed tomography were defined as group S (n = 13) and those without it were defined as group P (n = 17). A comparative group comprising patients with unruptured intracranial aneurysm was defined as group C (n = 30). The results of various cognitive and intelligence tests and a composite cognitive score were compared between groups. RESULTS: The digit span test forward version ( P = .041), frontal assessment battery ( P = .022), and composite cognitive score ( P = .015) z-scores were significantly lower in group S than group C. Adjusting for sex and age, patients in group S had a significantly lower composite cognitive score compared with those in group C in multiple regression analysis ( P = .037). Executive dysfunction and working memory dysfunction may be involved in the cognitive decline observed in group S. CONCLUSION: Mild cognitive dysfunction in MMD was associated with frontal lobe hemodynamic insufficiency. Future studies should examine whether revascularization can improve cerebral hypoperfusion and neurocognitive function in these patients.

Inverse Association Between Persistence With Antidepressant Medication and Onset of Chronic Pain in Patients With Depression: A Retrospective Cohort Study.

PURPOSE/BACKGROUND: Despite the known involvement of depression in chronic pain, the association between persistence with and adherence to antidepressant medication and onset of chronic pain in patients with depression remains unclear. METHODS/PROCEDURES: This retrospective cohort study used a Japanese claims database to extract data for adult patients with depression who were prescribed antidepressants between April 2014 and March 2020. Patients were divided into groups according to duration of continuous prescription of antidepressants (≥6 months [persistent group] and <6 months [nonpersistent group]) and medication possession ratio (≥80% [good adherence group] and <80% [poor adherence group]). The outcome was onset of chronic pain, which was defined as continuous prescription >3 months of analgesics and diagnosis of pain-related condition after discontinuation of the first continuous antidepressant prescription. The risk of onset of chronic pain was compared between the paired groups. FINDINGS/RESULTS: A total of 1859 patients were selected as the study population and categorized as the persistent (n = 406) and nonpersistent (n = 1453) groups, and good adherence (n = 1551) and poor adherence (n = 308) groups. Risk of onset of chronic pain was significantly lower in the persistent group than in the nonpersistent group after controlling for confounding via standardized mortality ratio weighting (hazard ratio, 0.38; 95% confidence interval, 0.18-0.80; P = 0.011). There was no significant difference between the good and poor adherence groups. IMPLICATIONS/CONCLUSIONS: Antidepressant persistence for ≥6 months is recommended and may reduce the onset of chronic pain in patients with depression.

Comparison of postoperative temporalis muscle atrophy between the muscle-preserving pterional approach and the mini-pterional approach in the treatment of unruptured intracranial aneurysms.

This study aimed to compare the muscle-preserving pterional approach (modified classic pterional approach, mCP) and the mini-pterional approach (mPA) with respect to postoperative temporalis muscle atrophy.From November 2013 to April 2020, 78 patients with unruptured intracranial aneurysm of the anterior circulation underwent surgery using mCP or mPA in our institution. Patients' background characteristics, postoperative complications, and temporalis muscle volume (MV) rates (operative side/healthy side) were retrospectively investigated. In 64 patients (n = 31, mCP group; n = 33, mPA group), excluding 14 patients with missing imaging data from 6 to 24 months after surgery, associations between the MV rate and clinical variables were assessed. A multiple regression model was used to examine the association between the MV rate and the surgical method, which is a predictor of postoperative atrophy.The mCP group had a significantly higher mean MV rate than the mPA group (0.955 ± 0.040 and 0.915 ± 0.070, respectively; p = 0.008). Based on the results of the univariate analysis, a multiple regression model was established using sex, age, follow-up period, and the presence of diabetes in addition to the surgical method. Patients who underwent mCP had a higher MV rate than those who underwent mPA (t value = 2.33, p = 0.023).The present result suggested that mCP has a preventive effect on postoperative temporalis muscle atrophy. However, further studies are needed in order to prove that mCP is also effective in terms of postoperative aesthetic and functional outcomes.

Positive urine culture under indwelling urethral catheterization is a risk factor for febrile complications after holmium laser enucleation of the prostate (HoLEP).

OBJECTIVES: To investigate the incidence of and risk factors for febrile complications (FCs) in patients undergoing holmium laser enucleation of the prostate (HoLEP). METHODS: This retrospective study enrolled 847 consecutive patients who underwent HoLEP in our hospital from June 2006 to December 2018. FCs were defined as a body temperature ≥38.0°C within 30 days after surgery. The incidence of FCs was determined and possible risk factors assessed using multivariate logistic regression analysis. RESULTS: Overall, 87 (10.3%) patients presented with FCs, and 6 (0.7%) had urosepsis, with no fatal complications. Multivariate logistic regression analysis revealed that patients with preoperative positive urine culture and urethral catheterization had an increased risk of FCs compared with those with a negative culture who did not need catheterization (odds ratio [OR] 2.587, 95% confidence interval [CI] 1.307-5.121). A negative urine culture with catheterization and a positive culture without catheterization were not associated with the development of FCs (OR 0.320, 95% CI 0.040-2.553 and OR 1.370, 95% CI 0.662-2.365, respectively). Other significant risk factors included preoperative serum albumin levels (OR 0.382, 95% CI 0.173-0.846) and immediate postoperative body temperature (OR 2.559, 95% CI 1.549-4.230). CONCLUSIONS: FCs are relatively common among patients after HoLEP despite preoperative prophylactic antibiotic administration. Surgeons may need to consider performing screening of urine cultures prior to HoLEP, especially in patients with urethral catheterization, even if asymptomatic. If the culture is positive, prophylactic antibiotics should be tailored according to bacterial susceptibility.

Relationship of Annual Health Checkups with the Subject's Subsequent Behavior of Cardiovascular Risk Management in a Real-World Setting in Japan: A Retrospective Cohort Study on Changes in Antihypertensive Drug Prescription and Blood Pressure from 2015 to 2017.

BACKGROUND: In Japan, workers receive a health checkup annually, and based on the results, a follow-up health guidance or intervention is provided when deemed necessary. However, it remains unclear whether the current real-world health checkup and guidance programs in Japan successfully lead to behavioral changes or improvement of clinical outcomes in individuals who require cardiovascular (CV) risk management. OBJECTIVE: This study aimed to explore the association between health checkup and the subsequent behavior change in CV risk management in subjects with uncontrolled blood pressure (BP) without antihypertensive drug prescription, who can have increased risk of CV events. PATIENTS AND METHODS: This was a retrospective cohort study that used health-checkup and claims data from a Japanese healthcare database managed by MinaCare Co., Ltd. Of those aged 20-74 years with available data on systolic and diastolic BP from 2015 to 2017, data from individuals with uncontrolled BP who were not prescribed antihypertensive drugs within 6 months before their baseline health checkup in 2015 were extracted and analyzed. The primary outcome measures were changes in antihypertensive drug prescription and BP control status based on health-checkup results from the baseline year (2015) to 2017. CV risk-management behavior was also assessed using body mass index (BMI) and smoking status, as these are the major modifiable CV risk factors. RESULTS: Among 39,242 subjects with uncontrolled BP without antihypertensive drug prescription at baseline, 88.9% remained without prescription in 2016. Of the subjects without prescription, 62.9% continued to have uncontrolled BP. Both statuses of the major modifiable CV risk factors remained unchanged in 2016: 92.1% of obese subjects (BMI ≥ 25 kg/m2) at baseline remained obese, and 93.8% of smokers at baseline aged ≥ 40 years continued to smoke. Logistic regression analysis revealed that age 60-69 years (vs. 40-49 years), hypertension (HT) stage II (vs. stage I), HT stage III (vs. stage I), and BMI ≥ 25.0 kg/m2 (vs. < 25.0 kg/m2) were factors associated with uncontrolled BP in 2016 (subsequent year), regardless of antihypertensive drug prescription. CONCLUSIONS: Untreated HT for years increases the risk of CV events. These results suggest that current health-checkup and guidance programs are inadequately effective for behavioral change. Further practices for committing to lifestyle modifications and seeking medical advice based on their health-checkup results need to be undertaken to improve health behavior.

Unawareness of having hypertension, dyslipidemia, and diabetes among medicated individuals.

AIMS: The objectives of this study were to assess the level of disease awareness in medicated patients with hypertension, dyslipidemia, or diabetes and to identify potential predictors of unawareness. METHODS: A total of 17,323 participants who visited an institution for a medical checkup between 2009 and 2017 were investigated retrospectively. Disease unawareness was defined as taking medication for a disease but not being aware of having that disease. RESULTS: Among the medicated participants, 10% (169/1658), 30% (278/919), and 5% (21/389) were unaware of having hypertension, dyslipidemia, and diabetes, respectively. Multivariate analysis identified male sex as an independent predictive factor for unawareness of having hypertension. Participants who had an alcohol consumption habit, higher body mass index (BMI), or higher systolic blood pressure had a lower risk of hypertension unawareness. Male sex and BMI were identified as independent predictive factors for unawareness of having dyslipidemia. Participants with higher hemoglobin A1C levels were at decreased risk of diabetes unawareness. CONCLUSIONS: A relatively large number of medicated participants were unaware of the disease they were being treated for. Explanatory factors for disease unawareness included male sex, no alcohol consumption, lower BMI, and disease-related factors, such as lower blood pressure and hemoglobin A1C levels.

The Use of Cumulative Sum Analysis to Derive Institutional and Surgeon-Specific Learning Curves for Robot-Assisted Radical Prostatectomy.

Purpose: The cumulative sum (CUSUM) approach has been adopted to evaluate surgical competence in various contexts. The CUSUM method comprises sequential monitoring of cumulative differences from a target level in performance quality over time, allowing the detection of deviations from the target. We use the CUSUM method in this study to derive both institutional and surgeon-specific learning curves for robot-assisted radical prostatectomy (RARP). Patients and Methods: We reviewed 540 patients diagnosed with localized prostate cancer (pathologic stage T2) who underwent RARP at our institution between September 2011 and December 2017. The CUSUM method was used to construct both institutional and individual-surgeon learning curves; the outcome was assessed based on whether a positive surgical margin (PSM) was present. The target PSM rate was 20%. Of seven surgeons performing robot-assisted resections for this period, four who performed ≥60 resections were assessed separately. Results: Of 540 patients, 74 (14%) had PSMs. The institutional CUSUM chart exhibited a downward trend for the first 54 cases and an upward trend thereafter. The CUSUM chart for the earliest adopter was similar to that for the institution; that is, learning was complete at 45 cases. Two adopters did not undergo a learning curve as they consistently performed well. The last adopter required 10 cases for initial learning. However, his CUSUM chart trend became negative at 46 cases and remained so afterward. Conclusions: CUSUM charts are useful for monitoring surgical quality. Long-term monitoring of the PSM rate of a surgeon who has become independent allows an attending surgeon to intervene if necessary; thus, long-term quality control is assured.

Relationship Between Intraprostatic Urethral Sphincter Status and Prostate Volume as Revealed by Magnetic Resonance Imaging.

OBJECTIVE: To evaluate the relationship between the lengths of 2 regions of the intraprostatic urethral sphincter, the distal region (from the apex to the adenoma [AA]) and the proximal region (from the adenoma to the verumontanum [AV]) and prostate volume (PV) in patients with clinical benign prostate hyperplasia. MATERIALS AND METHODS: A total of 110 patients who underwent magnetic resonance imaging before holmium laser enucleation of the prostate were enrolled. The lengths of 2 distinct intraprostatic urethral regions were measured on magnetic resonance imaging, and we used multiple regression analysis to explore the association between these lengths and PV. RESULTS: The median age was 69 years. The median AV and AA lengths were 6.0 and 5.7 mm, respectively. Multiple regression analysis to predict PV revealed that the interaction between age and AV length was significant (P = .012), whereas that between age and AA length was not (P = .819). In patients aged ≥69 years, the AV length was significantly positively associated with the PV (P = .005); in patients aged ≤69 years, a nonsignificant positive association was observed (P = .130). The AA length was not associated with the PV in either subgroup (P = .621 in those aged <69 years and P = .189 in those aged ≥69 years). CONCLUSION: Our results may indicate that the proximal length, which is covered by the adenoma, becomes longer as prostate hyperplasia progresses, whereas the distal length does not. It may be important to preserve the intraprostatic length of the striated sphincter when the urethra is dissected at the apex during radical prostatectomy.

Comorbidities as predictors of incidental prostate cancer after Holmium laser enucleation of the prostate: diabetes and high-risk cancer.

Prostate cancer can be diagnosed as an incidental finding during the pathological examination of benign prostatic hyperplasia (BPH) specimens by Holmium laser enucleation of the prostate (HoLEP). BPH and comorbidities such as hypertension, diabetes, and dyslipidemia often coexist in elderly people. We identified which comorbidities can be used to predict the presence of incidental prostate cancer, particularly high-risk cancer, in men who had undergone HoLEP. On the basis of pathological findings of HoLEP specimens, patients with incidental cancer were categorized as low-risk (Gleason ≤6 and T1a) or high-risk (all others). Of the 654 patients who underwent HoLEP, 41 patients (6.3%) were identified as having incidental cancer (25 low-risk and 16 high-risk). There were no significant factors for overall prostate cancers. However, a significantly higher frequency of diabetes was observed in patients with high-risk cancer compared to those with BPH (31% vs. 13%; p = .033). Logistic regression analysis using prostate-specific antigen (PSA) and prostate volume (PV), and smoking showed that diabetes was an independent predictor of high-risk cancer (odds ratio, 3.15; 95% confidence interval, 1.06-9.43). Diabetes may be an important predictor of the presence of high-risk prostate cancer in men with BPH who have undergone HoLEP.

Extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases in conjunction with carotid endarterectomy for contralateral cervical carotid stenosis: clinical results and cognitive performance.

Clinical results as well as cognitive performances after extracranial to intracranial (EC-IC) bypass in conjunction with contralateral carotid endarterectomy (CEA) are poorly understood. Data from 14 patients who underwent unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease in conjunction with CEA for contralateral cervical carotid stenosis were retrospectively reviewed. Postoperative results were evaluated by MRI imagings. Nine patients also underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised (WMS-R) before and about 6 months after bilateral surgeries. Postoperative MRI follow-up (median, 8 months; interquartile range, 7-8 months) confirmed successful bypass in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypass and contralateral smooth patency at CEA portion in all patients. In the group rate analysis, all five postoperative NPE scores (Verbal IQ, Performance IQ, WMS-memory, WMS-attention, and Average scores of all those four scores) were improved relative to preoperative NPE scores. Performance IQ and Average score improvements were statistically significant. Clinical results after EC-IC bypass in conjunction with contralateral CEA were feasible. Based on the group rate analysis, we conclude that successful unilateral EC-IC bypass and contralateral carotid endarterectomy does not adversely affect postoperative cognitive function.

Postoperative transient neurological symptoms and chronic subdural hematoma after extracranial-intracranial bypass for internal carotid/middle cerebral atherosclerotic steno-occlusive diseases: negative effect on cognitive performance.

BACKGROUND: The mechanisms underlying post-extracranial to intracranial (EC-IC) bypass neurocognitive changes are poorly understood. METHODS: Data from 55 patients who underwent a unilateral EC-IC bypass for atherosclerotic internal carotid artery (ICA)/middle cerebral artery (MCA) steno-occlusive disease were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and Wechsler Memory Scale-Revised (WMS-R) before and 6 months after EC-IC bypass. Results of NPEs were converted into Z-scores from which preoperative cognitive composite scores (CSpre) and postoperative cognitive composite scores (CSpost) were obtained. The association between the change of composite score between pre- and postoperative NPEs (CSpost-pre = CS post - CS pre) and various variables were assessed. These latter variables included occluded artery (ICA or MCA), preexisting ischemic lesion as verified in preoperative T2WI, robust bypass patency as verified by MRA performed approximately 6 months postoperatively, and postoperative transient neurological symptoms and/or postoperative chronic subdural hematoma (CSDH), both of which were dichotomized as postoperative events. RESULTS: Postoperative MRI follow-up (median, 6 months; interquartile range, 5-8 months) confirmed successful bypasses in all patients, with no additional ischemic lesions on T2WI when compared with preoperative imaging. Further, MRA showed patent bypasses in all patients. A nearly statistically significant CS post-pre decrease was observed in patients with postoperative events when compared with those without postoperative events (-0.158 vs. 0.039; p = 0.069). A multiple regression model predicting CSpost-pre was performed. After controlling for occluded arteries, postoperative events were identified as an independent predictor of a decline in CSpost-pre (p = 0.044). In the group rate analysis, three of four postoperative NPE scores (Performance IQ, WMS-memory, WMS-attention) were significantly improved relative to preoperative NPE scores. CONCLUSIONS: Postoperative transient neurological symptoms and/or CSDH might play a significant role in the subtle decline in cognition following an EC-IC bypass. However, this detrimental effect was small, and based on the group rate analysis, we concluded that a successful unilateral EC-IC bypass does not adversely affect postoperative cognitive function.

Abdominal obesity, hypertension, antihypertensive medication use and biochemical recurrence of prostate cancer after radical prostatectomy.

BACKGROUND: The aim of this study was to determine whether abdominal obesity, including visceral adipose tissue (VAT) measured by computed tomography and blood pressure (BP) were associated with biochemical recurrence of prostate cancer after prostatectomy. METHODS: We investigated 283 patients who underwent radical prostatectomy for prostate cancer retrospectively. We obtained information on body mass index (BMI), waist circumference (WC), VAT, BP, antihypertensive drug use, pretreatment prostate-specific antigen levels, pathological Gleason scores and postoperative surgical margin status. Hypertension was defined as systolic BP (SBP)⩾130mmHg or diastolic BP⩾85mmHg. RESULTS: Among 283 patients, 41 (14%) developed biochemical recurrence subsequently. We performed a Cox proportional hazard regression analysis to assess the association of each obesity measurement and SBP with biochemical recurrence using clinical predictors as potential confounders. No association was observed between any obesity measurement assessed and biochemical recurrence. Adjusting for each of BMI, WC and VAT, a higher SBP was associated significantly with biochemical recurrence (hazard ratio [HR], adjusted for VAT=1.04; 95% confidence interval [CI]=1.02-1.07). Adjusting for obesity (BMI⩾25kg/m(2)), hypertension was also associated significantly with biochemical recurrence (HR=2.08; 95% CI=1.09-3.97). Compared with normotensive patients, those with untreated and uncontrolled hypertension had a significantly increased risk of biochemical recurrence (HR=2.45; 95% CI=1.06-5.66). CONCLUSIONS: A higher BP and untreated, uncontrolled hypertension were independent risk factors for biochemical recurrence after prostatectomy. Control of hypertension could be an important treatment strategy for preventing biochemical recurrence.

Spinal cerebrospinal fluid leaks detected by radionuclide cisternography and magnetic resonance imaging in patients suspected of intracranial hypotension.

PURPOSE: Although many studies have described various features of neuroimaging tests associated with intracranial hypotension, few have examined their validity and reliability. We evaluated the association between CSF leaks detected by radionuclide cisternography and abnormal MRI findings in the accurate diagnosis of intracranial hypotension. PATIENTS/METHODS: We retrospectively assessed 250 patients who were suspected of intracranial hypotension and underwent subsequent radionuclide cisternography. We obtained 159 sagittal and 153 coronal T2-weighted MRI images and 101 gadolinium-enhanced T1-weighted MRI images. We assessed the CSF leaks in relation to a sagging brain, the maximum subdural space in sagittal and coronal images, and dural enhancement. RESULTS: Overall, 186 (74%) patients showed CSF leaks on radionuclide cisternography. A sagging brain was observed in 21 (13%) of the 159 patients with sagittal MRIs. A sagging brain was not associated with CSF leaks (14% vs. 10%; p=0.49). Compared to patients without CSF leaks, those with CSF leaks tended to have a larger maximum subdural space in both the sagittal (3.7 vs. 4.1mm) and coronal (2.5 vs. 2.8mm) images; however, the differences were not significant (p=0.18 and p=0.53, respectively). Dural enhancement was observed only in one patient, who presented with CSF leaks on radionuclide cisternography. CONCLUSIONS: Our study, which included a relatively large population, did not find any association between the findings of radionuclide cisternography and MRI. Future research should focus on identifying more valid neuroimaging findings to diagnose intracranial hypotension accurately.

Subtle structural change demonstrated on T2-weighted images after clipping of unruptured intracranial aneurysm: negative effects on cognitive performance.

OBJECT: The mechanisms underlying neurocognitive changes after surgical clipping of unruptured intracranial aneurysms (UIAs) are poorly understood. The aim of this study was to investigate factors that determine postoperative cognitive decline after UIA surgery. METHODS: Data from 109 patients who underwent surgical clipping of a UIA were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised before and 6 months after surgical clipping of the UIA. Results of NPEs were converted into z scores, from which pre- and postoperative cognitive composite scores (CSpre and CSpost) were obtained. The association between the change in CS between pre- and postoperative NPEs (that is, CSpost - CSpre [CSpost - pre]) and various variables was assessed. These latter variables included surgical approach (anterior interhemispheric approach or other approach), structural change evidenced on T2-weighted imaging at 6 months, somatosensory evoked potential amplitude decrease greater than 50% during aneurysm manipulation, preexisting multiple ischemic lesions in the lacunar region detected on preoperative T2-weighted imaging, and total microsurgical time. Paired t-tests of the NPE scores were performed to determine the net effect of these factors on neurocognitive function at 6 months. RESULTS: A significant CSpost - pre decrease was observed in patients with a structural change on postoperative T2-weighted imaging when compared with those without such a change on postoperative T2-weighted imaging (-0.181 vs 0.043, p = 0.012). Multiple regression analysis demonstrated that postoperative T2-weighted imaging change independently and negatively correlated with CSpost - pre (p = 0.0005). In group-rate analysis, postoperative NPE scores were significantly improved relative to preoperative scores. CONCLUSIONS: Minimal structural damage visualized on T2-weighted images at 6 months as a result of factors such as pial/microvascular injury and excessive retraction during surgical manipulation could cause subtle but significant negative effects on postoperative neurocognitive function after surgical clipping of a UIA. However, this detrimental effect was small, and based on the group-rate analysis, the authors conclude that successful and meticulous surgical clipping of a UIA does not adversely affect postoperative cognitive function.

Relationship between prostate-specific antigen levels and ambient temperature.

We examined the association between prostate-specific antigen (PSA) and daily mean ambient temperature on the day of the test in healthy men who had three annual checkups. We investigated 9,694 men who visited a hospital for routine health checkups in 2007, 2008, and 2009. Although the means and medians of ambient temperature for the three years were similar, the mode in 2008 (15.8 °C) was very different from those in 2007 and 2009 (22.4 °C and 23.2 °C). After controlling for age, body mass index, and hematocrit, a multiple regression analysis revealed a U-shaped relationship between ambient temperature and PSA in 2007 and 2009 (P<0.001 and P=0.004, respectively), but not in 2008 (P=0.779). In 2007, PSA was 13.5% higher at 5 °C and 10.0% higher at 30 °C than that at 18.4 °C (nadir). In 2009, PSA was 7.3% higher at 5 °C and 6.8% at 30 °C compared with the level at 17.7 °C (nadir). In logistic regression analysis, a U-shaped relationship was found for the prevalence of a higher PSA (>2.5 ng/mL) by ambient temperature, with the lowest likelihood of having a high PSA at 17.8 °C in 2007 (P=0.038) and 15.5 °C in 2009 (P=0.033). When tested at 30 °C, there was a 57% excess risk of having a high PSA in 2007 and a 61% higher risk in 2009 compared with those at each nadir temperature. We found a U-shaped relationship between PSA and ambient temperature with the lowest level of PSA at 15-20 °C.

Stratification of intraoperative ischemic impact by somatosensory evoked potential monitoring, diffusion-weighted imaging and magnetic resonance angiography in carotid endarterectomy with routine shunt use.

BACKGROUND: Routine shunting to minimize ischemia during carotid endarterectomy (CEA) is controversial. The aim of this study was to stratify the ischemic parameters associated with CEA and evaluate the effect of routine shunting in attempting to mitigate those ischemia. METHOD: Data from 248 CEAs with routine shunting were retrospectively evaluated. Our assessment included somatosensory evoked potential (SSEP) amplitude reduction more than 50 % and longer than 5 min (SSEP<50%, >5 min), new postoperative diffusion-weighted imaging lesions (new DWI lesions), and severe stenosis as indicated by reduced ipsilateral middle cerebral artery (MCA) signal on preoperative magnetic resonance angiography (MRA asymmetry), as surrogates of hypoperfusion, microembli, and hemodynamic impairment, respectively. RESULTS: SSEP<50%, >5 min occurred in 15 % of CEAs during cross-clamping, and shunting reversed the SSEP changes. New DWI lesions were observed in 4.1 %. Pre-clamping the common and external carotid artery during dissection (pre-clamp method) decreased the rate of new DWI lesions compared to without pre-clamping (3.5 % vs. 7.5 %, P = 0.22). Occlusion time was significantly longer in the pre-clamp method than without pre-clamping (P < 0.0001). However, the incidence of SSEP<50%, >5 min was not increased with the pre-clamp method (p = 1.0) when using information regarding SSEP and collaterals to modify the speed of shunt manipulation. MRA asymmetry was identified in 39 CEAs (15.8 %) with correction of asymmetry postoperatively. MRA asymmetry correlated with symptomatic hyperperfusion (P = 0.0034). Only three CEAs had symptomatic hyperperfusion (1.2 %) with minimal symptoms. Ten CEAs sustained transient ischemia, symptomatic hyperperfusion, or 30-day-stroke (composite postoperative ischemic symptoms). Logistic regression analysis confirmed that SSEP<50%, >5 min (p = 0.009), new DWI lesions (p = 0.004) and MRA asymmetry (p = 0.042) were independent predictors of　composite postoperative ischemic symptoms. CONCLUSIONS: SSEP<50%, >5 min, new DWI lesions, and MRA asymmetry were able to stratify the ischemic impacts in CEA. Meticulous routine shunting could mitigate those appropriately.

Subclinical ischemia verified by somatosensory evoked potential amplitude reduction during carotid endarterectomy: negative effects on cognitive performance.

OBJECT: Although the mechanisms underlying neurocognitive changes after carotid endarterectomy (CEA) are poorly understood, intraoperative ischemia and postoperative hemodynamic changes may play a role. METHODS: Data from 81 patients who underwent unilateral CEA with routine shunt use for carotid artery stenosis were retrospectively evaluated. These patients underwent neuropsychological examinations (NPEs), including assessment by the Wechsler Adult Intelligence Scale-Third Edition and the Wechsler Memory Scale-Revised before and 6 months after CEA. results of NPEs were converted into z scores, from which pre- and postoperative cognitive composite scores (CSpre and CSpost) were obtained. The association between the change of CS between pre- and postoperative NPEs (that is, CSpost - CSpre [CSpost - pre]) and various variables was assessed. These latter variables included ischemic or hemodynamic parameters such as 1) intraoperative hypoperfusion detected by somatosensory evoked potential (SSEP) change-that is, an SSEP amplitude reduction more than 50% and longer than 5 minutes (SSEP< 50%, > 5 min); 2) new lesions on postoperative diffusion-weighted imaging studies; and 3) preexisting hemodynamic impairment. Paired t-tests of the NPE scores were performed to determine the net effect of these factors on neurocognitive function at 6 months. RESULTS: A significant CSpost - pre decrease was observed in patients with SSEP< 50%, > 5 min when compared with those without SSEP< 50%, > 5 min (-0.225 vs 0.018; p = 0.012). Multiple regression analysis demonstrated that SSEP< 50%, > 5 min independently and negatively correlated with CSpost - pre (p = 0.0020). In the group-rate analysis, postoperative NPE scores were significantly improved relative to preoperative scores. CONCLUSIONS: Hypoperfusion during cross-clamping, as verified by SSEP amplitude reduction, plays a significant role in the subtle decline in cognition following CEA. However, this detrimental effect was small, and various confounding factors were present. Based on these observations and the group-rate analysis, the authors conclude that successful unilateral CEA with routine shunt use does not adversely affect postoperative cognitive function.

Hypercholesterolemia is associated with a lower risk of cerebral ischemic small vessel disease detected on brain checkups.

OBJECTIVE: Several studies have reported an association between low cholesterol levels and cerebral small vessel disease (SVD). In this study, we examined whether serum total cholesterol was associated with SVD, including lacunar infarctions and white matter hyperintensity, detected by magnetic resonance imaging (MRI), in participants who had a checkup of the brain. METHODS: We retrospectively investigated 6143 participants aged 40 and over who visited a hospital for a brain checkup in a cross-sectional design. We performed logistic regression analysis to examine the association between total cholesterol and SVD. RESULTS: SVD was observed in 1456 participants (24%). Adjusting for sex, age, body mass index, hypertension, hypertriglyceridemia, and diabetes, a total cholesterol≥225mg/dL (the highest quartile) was significantly associated with not having SVD compared with a total cholesterol<178mg/dL (the lowest quartile; odds ratio [OR], 0.708; 95% confidence interval [CI], 0.581-0.863). Participants with a total cholesterol of 200-225mg/dL (the third quartile) tended to have a reduced risk of SVD (OR, 0.832; 95%CI, 0.689-1.005). CONCLUSION: Hypercholesterolemia was significantly associated with a lower risk of SVD, detected by MRI, in participants undergoing a brain checkup, after adjusting for potential confounding factors, such as age and hypertension.