Occlusal Support, Dysphagia, Malnutrition, and Activities of Daily Living in Aged Individuals Needing Long-Term Care: A Path Analysis.

OBJECTIVES: This study aimed to examine the interrelationships among occlusal support, dysphagia, malnutrition, and activities of daily living in aged individuals needing long-term care. DESIGN: Cross-sectional study and path analysis. SETTING: Long-term health care facilities, acute care hospitals, and the community. PARTICIPANTS: Three hundred and fifty-four individuals aged ≥ 65 years with dysphagia or potential dysphagia in need of long-term care. MEASUREMENTS: The modified Eichner Index, Dysphagia Severity Scale, Mini Nutritional Assessment Short Form, and Barthel index. RESULTS: The participants included 118 males and 236 females with a mean (standard deviation) age of 83 (8) years. A total of 216 participants had functional occlusal support with or without dentures. Of the total participants, 73 were within normal limits regarding the severity of dysphagia, 119 exhibited dysphagia without aspiration, and 162 exhibited dysphagia with aspiration. Only 34 had a normal nutritional status, while 166 participants were malnourished, and 154 were at risk of malnutrition. The median Barthel index score was 30. Path analysis indicated two important findings: occlusal support had a direct effect on dysphagia (standard coefficient = 0.33), and dysphagia was associated directly with malnutrition (standard coefficient = 0.50). Dysphagia and malnutrition were associated directly with impaired activities of daily living (standard coefficient = 0.57, 0.22). CONCLUSION: In aged individuals needing long-term care, occlusal support is associated directly with dysphagia and indirectly with malnutrition and activities of daily living via dysphagia.

Clinical and mutational spectrum of Charcot-Marie-Tooth disease type 2Z caused by MORC2 variants in Japan.

BACKGROUND AND PURPOSE: The microrchidia family CW-type zinc finger 2 gene (MORC2) was newly identified as a causative gene of Charcot-Marie-Tooth disease (CMT) type 2Z in 2016. We aimed to describe the clinical and mutational spectrum of patients with CMT harboring MORC2 mutations in Japan. METHODS: We analyzed samples from 781 unrelated patients clinically diagnosed with CMT using deoxyribonucleic acid microarray or targeted resequencing by next-generation sequencing, and samples from 434 mutation-negative patients were subjected to whole-exome sequencing. We extracted MORC2 variants from these whole-exome sequencing data and classified them according to American College of Medical Genetics standards and guidelines. RESULTS: We identified MORC2 variants in 13 patients. As the second most common causative gene of CMT type 2 after MFN2, MORC2 variants were detected in 2.7% of patients with CMT type 2. The mean age of onset was 10.3 ± 8.7 years, and the inheritance pattern was mostly sporadic (11/13 patients, 84.6%). The clinical phenotype was typically length-dependent polyneuropathy, and electrophysiological studies revealed sensory-dominant axonal neuropathy. Mental retardation was identified in 4/13 patients (30.8%). p.Arg190Trp, as a mutational hotspot, was observed in eight unrelated families. We also identified two novel probably pathogenic variants, p.Cys345Tyr and p.Ala369Val, and one novel uncertain significance variant, p.Tyr332Cys. CONCLUSIONS: Our study is the largest report of patients harboring MORC2 variants. We revealed a clinical and mutational spectrum of Japanese patients with MORC2 variants. More attention should be paid to cognitive impairment, and the responsible mechanism requires further research for elucidation.

Neck Circumference Is Not Associated with Dysphagia but with Undernutrition in Elderly Individuals Requiring Long-term Care.

OBJECTIVES: The purpose was to assess the association between neck circumference, dysphagia, and undernutrition in elderly individuals requiring long-term care. DESIGN: Cross-sectional study. SETTING: Geriatric health services facilities, acute hospitals, and the community. PARTICIPANTS: Elderly individuals ≥65 years of age with dysphagia or possible dysphagia (N=385). MEASUREMENTS: Neck circumference, the Dysphagia Severity Scale (DSS) and the Mini Nutritional Assessment Short Form (MNA-SF). RESULTS: Participants included 130 males and 255 females with a mean age (± standard deviation) of 83 ± 8.0 years. Sixty-six were in acute hospitals, 195 were in geriatric health services facilities, and 124 were community-dwelling. The mean neck circumference in males and females was 37.1 ± 3.0 cm and 33.3 ± 3.3 cm, respectively. Based on the DSS, 81 participants were within normal limits, 137 had dysphagia without aspiration, and 167 had dysphagia with aspiration. The MNA-SF revealed that 173 were malnourished, 172 were at risk of malnutrition, and 40 had a normal nutritional status. Neck circumference was not significantly correlated with the DSS (r=-0.080) but was significantly correlated with the MNA-SF (r=0.183) in the Spearman rank correlation analysis. In the logistic regression, neck circumference was not independently associated with the DSS after adjusting for the MNA-SF, the Barthel Index, age, sex, setting, and cerebrovascular disorders. However, the multiple regression analysis showed that neck circumference had an independent effect on the MNA-SF after adjusting for the Barthel Index, age, sex, setting and cerebrovascular disorders. CONCLUSIONS: Neck circumference is not associated with dysphagia but with undernutrition in elderly individuals requiring long-term care.

Dysphagia Assessed by the 10-Item Eating Assessment Tool Is Associated with Nutritional Status and Activities of Daily Living in Elderly Individuals Requiring Long-Term Care.

OBJECTIVES: The 10-item Eating Assessment Tool (EAT-10) is a self-administered questionnaire for dysphagia screening, with each item scored from 0 to 4. We assessed the associations among the EAT-10 score, nutritional status and activities of daily living (ADL) in elderly individuals requiring long-term care. DESIGN: Cross-sectional study. SETTING: Geriatric health services facilities, acute hospitals, and the community. PARTICIPANTS: Elderly individuals ≥65 years of age with dysphagia or possible dysphagia (N=237). MEASUREMENTS: The EAT-10, the Mini Nutritional Assessment Short Form (MNA-SF) and the Barthel Index. RESULTS: There were 90 males and 147 females. Mean age was 82 ± 8 years. Eighty-nine were in geriatric health services facilities, 28 were in acute hospitals, and 120 were community-dwelling. The median Barthel Index score was 55 (interquartile range: 25, 80). The median EAT-10 score was 1 (interquartile range: 0, 9), and 101 respondents a score > 3, indicating the presence of dysphagia. The MNA-SF revealed that 81 were malnourished, 117 were at risk of malnutrition, and 39 had a normal nutritional status. The Barthel Index score and MNA-SF score were significantly lower in those with an EAT-10 score between 3 and 40, compared to those with an EAT-10 score between 0 and 2. The EAT-10 has an independent effect on the Barthel Index and the MNA-SF by adjusting for covariates such as age, gender, and setting in multiple regression analysis. CONCLUSIONS: Dysphagia assessed by the EAT-10 is associated with nutritional status and ADL in elderly individuals requiring long-term care.

BMI is associated with larger index tumors and worse outcome after radical prostatectomy.

BACKGROUND: To investigate the impact of body mass index (BMI) on tumor characteristics and biochemical recurrence (BCR) after radical prostatectomy (RP) for prostate cancer (PCa) in Japanese men. METHODS: We evaluated data from consecutive patients who had undergone RP. Data analyzed included age, preoperative serum PSA, prostatic volume, BMI (continuous or categorized (≤ 25 kg/m(2)) values), clinical and pathological findings including index tumor volume (ITV), and current status in areas such as smoker or nonsmoker and presence or absence of diabetes. We analyzed association between BMI and BCR, especially based on ITV using univariate and multivariate analysis. RESULTS: We analyzed data from a total of 703 patients. The median follow-up time was 38.4 months. BCR was diagnosed in 154 patients (21.9%) at a median of 9.7 months postoperatively. Multivariate linear regression analysis adjusted for preoperative variables showed a significant positive association between BMI and ITV (continuous BMI: P=0.002; categorical BMI: P<0.001, respectively), especially for higher-grade tumors (Gleason score ≥ 7). Cox proportional hazards analysis showed a significant association between continuous BMI and BCR after surgery (preoperative variables, hazard ratio (HR) 1.09, 95% confidence interval (CI) 1.02-1.16, P=0.008), independent of clinical and pathological findings. In patients with high-risk cancer, the positive association between BMI and BCR was strengthened (preoperative variables, continuous BMI, HR 1.16, 95% CI 1.07-1.26, P<0.001; categorical BMI, HR 2.11, 95% CI 1.29-3.45, P=0.003, respectively). CONCLUSIONS: Greater BMI significantly correlates with higher rates of BCR after surgery; BMI is a preoperative variable associated with high-grade ITV. Our results suggest that the biological environment created by greater BMI may contribute to increasing tumor aggressiveness.

Chronic kidney disease categories and renal-cardiovascular outcomes in type 2 diabetes without prevalent cardiovascular disease: a prospective cohort study (JDDM25).

AIMS/HYPOTHESIS: In type 2 diabetic patients at low risk for cardiovascular disease (CVD), the relationship between the clinical course of nephropathy by stage of chronic kidney disease (CKD) and onset of CVD remains unclear. Clarification of this relationship is important for clinical decision-making for both low- and high-risk diabetic patients. METHODS: This 4 year prospective study enrolled 2,954 type 2 diabetic patients with no prevalent CVD, and serum creatinine <176.8 µmol/l. The risk for CVD onset (non-fatal and fatal CVD and stroke, and peripheral arterial disease) was assessed according to CKD stage categorised by urinary albumin-to-creatinine ratio (ACR; mg/mmol) and estimated GFR (eGFR; ml min(-1) 1.73 m(-2)). Association of progression from 'no CKD' stage (ACR <3.5 mg/mmol and eGFR ≥ 90 ml min(-1) 1.73 m(-2)) with risk for CVD onset was also evaluated. RESULTS: During follow-up (median 3.8 years), 89 CVD events occurred. Compared with patients with 'no CKD' as reference, those with ACR ≥ 35.0 mg/mmol with co-existing eGFR 60-89 ml min(-1) 1.73 m(-2) or <60 ml min(-1) 1.73 m(-2) showed increased risk for CVD onset, whereas those with eGFR ≥ 90 ml min(-1) 1.73 m(-2) did not. Those with ACR <3.5 mg/mmol and eGFR <60 ml min(-1) 1.73 m(-2) did not show any increased risk. Among patients with 'no CKD' stage at baseline, those who progressed to ACR ≥ 3.5 mg/mmol during follow-up showed an increased risk compared with those who did not, whereas those who progressed to eGFR <90 ml min(-1) 1.73 m(-2) did not have increased risk. CONCLUSIONS/INTERPRETATION: The risk for CVD was associated with progression of albuminuria stage rather than eGFR stage in type 2 diabetic patients at relatively low risk for CVD.

Double-balloon endoscopy versus magnet-imaging enhanced colonoscopy for difficult colonoscopies, a randomized study.

BACKGROUND AND STUDY AIMS: Studies have estimated that failure of cecal intubation occurs with conventional colonoscopy in up to 10 % of cases. Double-balloon endoscopy (DBE) systems, magnetic endoscope imaging (MEI), and transparent cap have been shown to improve success rates for colonoscopy. This study evaluated the utility of DBE for complete examination of the colon compared with MEI plus cap (MEI-Cap) after incomplete or technically difficult colonoscopy in a randomized comparative manner. PATIENTS AND METHODS: A total of 94 patients with incomplete or technically difficult colonoscopy were randomly assigned to receive either DBE (n = 47) or colonoscopy with MEI-Cap (n = 47). The primary end point was cecal intubation rate within 30 minutes. Secondary end points included intubation time, pain score using a visual analog scale, abdominal pressure attempts, doses of sedative medication, and changes in patient position during colonoscopy. RESULTS: Patient characteristics were comparable in both groups. Cecal intubation rate within 30 minutes was significantly higher for DBE (45 /47, 95.7 %) than for MEI-Cap (34 /47, 72.3 %) (P = 0.0049). Mean time to reach the cecum was significantly lower in the DBE group (13.0 ±â€Š5.3 minutes) than in the MEI-Cap group (16.4 ±â€Š4.8 minutes; P = 0.0003). No complications were encountered in either group.   CONCLUSION: DBE is more useful for complete examination of the colon than MEI-Cap in patients with incomplete or technically difficult colonoscopy.

Low incidence of cardiovascular events in Japanese patients with Type 2 diabetes in primary care settings: a prospective cohort study (JDDM 20).

AIMS: To investigate whether a reduced incidence of cardiovascular disease in Type 2 diabetes can be achieved in a newly recruited cohort following the recently advanced concept of multifactorial treatment and followed in primary care settings as compared with earlier cohorts. METHODS: A prospective study was performed in primary care settings at multiple clinics nationwide in the Japan Diabetes Clinical Data Management (JDDM) study group. Subjects were 2984 patients with Type 2 diabetes without prevalent cardiovascular disease. The main outcome measure was the first event of non-fatal or fatal coronary heart disease, ischaemic stroke or peripheral artery disease, and the incidence was compared with other representative cohorts. RESULTS: There were 90 cardiovascular events over 10,827 person-years of follow-up with a dropout rate of 6%. The incidences (per 1000 person-years, 95% confidence interval) of composite, coronary heart disease, ischaemic stroke and peripheral artery disease in the JDDM study were 8.3 (6.6-10.0), 4.4 (3.2-5.6), 3.1 (2.1-4.2), and 0.7 (0.2-1.2), respectively. Each incidence was lowest in the JDDM study compared with other cohorts (P < 0.01 vs. each cohort). In the JDDM study, significant variables predictive of the occurrence of a cardiovascular event were age, duration of diabetes, HbA(1c), HDL cholesterol and urinary albumin. CONCLUSION: The novel finding of low cardiovascular disease occurrence in this study may be conferred by the feasibility at primary care settings for providing patients with Type 2 diabetes with favourable control of blood glucose, blood pressure and lipids, coupled with unique ethnicity/country factors.

Photoelastic stress analysis in blood vessel phantoms: three-dimensional visualization and saccular aneurysm with bleb.

BACKGROUND: The photoelastic effect is used for stress measurement during endovascular surgery simulation for quantitative evaluation of catheter trajectory in in vitro environments. By extending the capabilities of this sensing technology, its potential for intravascular tools evaluation will increase. METHODS: In this research the error introduced by stress direction on magnitude measurements was studied, then stress measurements were made in the phantom modelling of a saccular aneurysm with bleb. To visualize three-dimensionally the stress field changes produced by a guide wire in a phantom wall, a scanner and an algorithm relying on maximum likelihood-expectation maximization are proposed. Three-dimensional fields at different pressure level were compared with the stress field surrounding the guide wire. RESULTS: The maximum error in stress magnitude measurements due to stress direction was 2.52%. Stress local maximum was detected in the bleb phantom before rupture. Three-dimensional visualization was obtained in vasculature phantom with average errors of 10.73%, 4.55%, 3.18% for inner pressures of 80, 120, 160 mmHg, respectively. Stress measurement in the neighbourhood of the guide wire is equivalent to applying an inner pressure of 120 mmHg. CONCLUSIONS: For the presented polariscope, the weak influence of stress direction in magnitude measurements was confirmed. In vasculature phantoms, the three-dimensional visualization of stress eliminated birefringence visualization distortion and enabled more comprehensive comparison of stress produced by intravascular tools with stress produced by normal blood pressure.

Comparison of accuracy of physical examination and endoanal ultrasonography for preoperative assessment in patients with acute and chronic anal fistula.

BACKGROUND: This study was undertaken to evaluate the accuracy of endoanal ultrasonography for preoperative assessment of anal fistula, with special reference to the difference between acute and chronic fistula. METHODS: The subjects comprised 401 patients treated for acute or chronic anorectal sepsis of cryptoglandular origin during the period January through December 2005. All patients underwent physical examination and endoanal ultrasonography. Agreement between the physical and endosonographic findings and the definitive surgical findings were evaluated with special reference to classification of the primary tract and horseshoe extension and localization of the internal opening. The difference in accuracy of endosonographic assessment between acute and chronic fistula was also evaluated. RESULTS: The accuracy of endoanal ultrasonography was significantly higher than that of physical examination in detecting the primary tract (88.8% vs. 85.0%, p=0.0287) and horseshoe extension (85.7% vs. 58.7%, p<0.0001) and in localizing the internal opening (85.5% vs. 69.1%, p<0.0001). Furthermore, localization of the internal opening by endosonography was significantly more accurate in chronic fistula than in acute fistula (89.5 % vs. 76.8%, p<0.0001), although the accuracy in detecting the primary tract and horseshoe extension was not significantly different. CONCLUSIONS: Endoanal ultrasonography is reliable and useful for preoperative assessment of anal fistula, particularly for detecting horseshoe extension and localizing the internal opening. Endosonographic assessment provides clearer depiction of the internal opening during periods of quiescence than during the period of abscess formation. For patients with acute anorectal sepsis, initial surgical drainage and subsequent fistula surgery, rather than one-stage fistula surgery, may be advisable to avoid misidentification of the internal opening.

Endoanal ultrasonography in the diagnosis and operative management of perianal endometriosis: report of two cases.

We report two cases of perianal endometriosis in which we were greatly assisted by endoanal ultrasonography. Patient 1 was a 43-year-old woman with perianal pain. Endosonography showed a hypoechoic mass in the anterior perianal region without involvement of the anal sphincter. Local excision was performed under spinal anesthesia without damage to the anal sphincter. Patient 2 was a 30-year-old woman with perianal pain coinciding with her menstrual period. Endosonography showed a heterogeneous mass containing cystic anechoic areas in the right anterior perianal region and involving the external anal sphincter. Wide excision, including the episiotomy scar and part of the external anal sphincter, and primary sphincteroplasty were performed under spinal anesthesia. According to our experience, preoperative endosonography is a reliable technique for visualizing perianal endometriosis and for diagnosing anal sphincter involvement. Operative management should be determined on the basis of preoperative and intraoperative ultrasonographic assessment.

Advantages of oxygen inhalation therapy for postoperative pulmonary hypertension.

Total correction was performed in a case of complete transposition of the great arteries (TGA) with severe pulmonary vascular obstructive disease (PVOD). Although severe pulmonary hypertension remained after surgery, oxygenation was continued for 15 months, which included a shift to at-home oxygen inhalation therapy (HOT). Cardiac catheterization 15 months after surgery demonstrated that pulmonary hypertension was greatly improved. For patients in whom the palliative Mustard operation is considered due to severe PVOD on the basis of lung biopsy diagnosis, total correction of TGA is possible by employing HOT after surgery.

[Short-term results of the Fontan operation in patients with Down syndrome].

Despite an extensive experience with Fontan operation, there is a paucity of information to guide the indication of the procedure in patients with Down syndrome. Of 79 patients who had undergone a Fontan operation in our hospital between 1995 and 2003, 3 had Down syndrome. All 3 patients had complete atrioventricular septal defect with single ventricular physiology. Two patients survived, and 1 died of chylothorax and respiratory infection. The 2 survivors have done well in the short-term without complications. We consider that in appropriately selected patients with Down syndrome in whom biventricular repair is precluded, the Fontan operation is the choice of the procedures.

Clinical study of urine NMP 22 (nuclear matrix protein 22) as a tumor marker in urinary epithelial cancer.

The prognosis of urinary epithelial cancer is still poor, and early detection of this cancer is strongly desirable. The sensitivity of conventional urinary cytology is not satisfactory enough. It is hoped that a specific tumor marker will be established. In recent years, it has been reported that urine NMP 22 is very useful and that urine BFP is also relatively useful. We have now determined urine NMP22 and BFP and studied their clinical usefulness as a tumor marker. Using patients diagnosed with histologically confirmed urinary epithelial cancer as the subjects, we retrospectively studied the usefulness of NMP 22, BFP and cytology mainly with regard to the sensitivity (positivity rate), and also in relation to atypia, degree of infiltration and clinical course.

Inhibition of arthritis by systemic administration of endostatin in passive murine collagen induced arthritis.

OBJECTIVE: To investigate the arthritis inhibiting effect of endostatin, known to have potent antiangiogenic activity, systemically given to animal models of rheumatoid arthritis (RA). METHODS: Four kinds of monoclonal anti-type II collagen antibody followed by lipopolysaccharide (LPS) three days later were given to 6 week old, female Balb/c mice to induce arthritis. Three groups of mice received 0.2 mg/kg/day, 2 mg/kg/day, and 10 mg/kg/day of endostatin, respectively, whereas a control group received phosphate buffered saline (PBS). Endostatin or PBS was given for 13 days, starting before the development of arthritis. Arthritis was evaluated by arthritis scores and hind paw thicknesses. Mice were killed for histological examination on the 22nd day after the administration of monoclonal anti-type II collagen antibody. RESULTS: Arthritis developed within three days after LPS administration in both the control and endostatin treatment groups. No difference in the development rate of arthritis was noted between the control and endostatin treatment groups. Arthritis scores remained significantly lower in the endostatin 10 mg/kg/day group than in the control group. Hind paw thicknesses also remained significantly smaller in the endostatin 10 mg/kg/day group than in the control group. Histopathological examination showed that synovial thickening and subchondral bone erosion improved more in the endostatin treatment groups than in the control group. CONCLUSION: The systemic administration of endostatin had an arthritis inhibiting effect in RA animal models. Endostatin inhibited, in particular, pannus formation and bone destruction.

Endothelin protein expression as a significant prognostic factor in oesophageal squamous cell carcinoma.

The aim of this study was to investigate if the expression of endothelin (ET), a vasoactive peptide, in cancerous oesophageal lesions, adjacent dysplastic tissue and normal mucosa might be prognostic. Tissue samples from a total of 101 patients with oesophageal squamous cell carcinoma were obtained and stained with ET antibody in an immunohistochemical analysis. High staining levels of ET within normal mucosa were related to lymph vessel invasion, regional lymph node metastasis and distant metastasis, as well as a reduced relapse-free survival (log-rank test; P=0.0066). After adjustment for several histological prognostic risk factors and each component of the TNM classification system, high ET expression within dysplastic tissue more than doubled the hazard ratio of relapse with significant model improvement. These results suggest that, in addition to known histological risk factors and TNM classification criteria, measurement of ET expression with a simple immunohistochemical analysis might further help in predicting the prognosis of patients with oesophageal squamous cell carcinoma.