Herpes Zoster Ophthalmicus Initially Diagnosed As Cluster Headache, Complicated by Delayed Eruption.

Herpes zoster ophthalmicus (HZO) manifests as a consequence of the reactivation of the Varicella-zoster virus (VZV) and primarily affects the ophthalmic division of the trigeminal nerve. Identification of the vesicular eruption is central to the diagnostic process; however, the delayed manifestation of this cutaneous phenomenon poses a challenge to timely and accurate diagnosis. This report elucidates the case of a 61-year-old Japanese male with painful trigeminal neuropathy attributed to VZV that was initially diagnosed as cluster headache, mainly due to the delayed cutaneous eruption. Contrary to the expected pattern of cluster headache presentations, there was no discernible fluctuation in headache severity. The transient improvement of symptoms following interventions tailored for cluster headache management, including pure oxygen inhalation and subcutaneous sumatriptan injection, inadvertently contributed to a delay in accurate diagnosis. The importance of distinguishing HZO from cluster headache is emphasized, particularly in cases involving elderly patients or those with persistent cephalo-ophthalmalgia without the characteristic fluctuation of symptoms. In cases where clinical suspicion of HZO is raised, cerebrospinal fluid analysis should be performed. This approach is consistent with the overall goal of facilitating a prompt and accurate diagnosis.

Whole Blood Spermine/Spermidine Ratio as a New Indicator of Sarcopenia Status in Older Adults.

Early diagnosis and therapeutic intervention improve the quality of life and prognosis of patients with sarcopenia. The natural polyamines spermine and spermidine are involved in many physiological activities. Therefore, we investigated blood polyamine levels as a potential biomarker for sarcopenia. Subjects were Japanese patients >70 years of age who visited outpatient clinics or resided in nursing homes. Sarcopenia was determined based on muscle mass, muscle strength, and physical performance according to the criteria of the Asian Working Group for Sarcopenia (2019). The analysis included 182 patients (male: 38%, age: 83 [76-90] years). Spermidine levels were higher (p = 0.002) and the spermine/spermidine ratio was lower (p < 0.001) in the sarcopenia group than in the non-sarcopenia group. Polyamine concentration analysis showed that the odds ratios for age and spermidine changed in parallel with sarcopenia progression, and the odds ratio for the spermine/spermidine ratio changed inversely with the degree of sarcopenia progression. Additionally, when the odds ratio was analyzed with spermine/spermidine instead of polyamine concentrations, only for spermine/spermidine, the odds ratio values varied in parallel with the progression of sarcopenia. Based on the present data, we believe that the blood spermine/spermidine ratio may be a diagnostic indicator of risk for sarcopenia.

Positive Correlation between Relative Concentration of Spermine to Spermidine in Whole Blood and Skeletal Muscle Mass Index: A Possible Indicator of Sarcopenia and Prognosis of Hemodialysis Patients.

Several mechanisms strictly regulate polyamine concentration, and blood polyamines are excreted in urine. This indicates polyamine accumulation in renal dysfunction, and studies have shown increased blood polyamine concentrations in patients with renal failure. Hemodialysis (HD) may compensate for polyamine excretion; however, little is known about polyamine excretion. We measured whole-blood polyamine levels in patients on HD and examined the relationship between polyamine concentrations and indicators associated with health status. Study participants were 59 hemodialysis patients (median age: 70.0 years) at Minami-Uonuma City Hospital and 26 healthy volunteers (median age: 44.5 years). Whole-blood spermidine levels were higher and spermine/spermidine ratio (SPM/SPD) was lower in hemodialysis patients. Hemodialysis showed SPD efflux into the dialysate; however, blood polyamine levels were not altered by hemodialysis and appeared to be minimally excreted. The skeletal muscle mass index (SMI), which was positively correlated with hand grip strength and serum albumin level, was positively correlated with SPM/SPD. Given that sarcopenia and low serum albumin levels are reported risk factors for poor prognosis in HD patients, whole blood SPM/SPD in hemodialysis patients may be a new indicator of the prognosis and health status of HD patients.

Cerebral oxygenation changes in response to post-hemodialysis standing.

Few reports have examined the association between changes in cerebral oxygenation and clinical factors, including blood pressure (BP), upon standing after hemodialysis (HD). This study aimed to clarify the factors affecting the changes in cerebral regional oxygen saturation (rSO2) upon standing after HD and monitor the differences in cerebral rSO2 changes that occur upon standing after HD in patients with and without diabetes mellitus (DM). Changes in mean BP and cerebral rSO2 were tracked in 43 HD patients during 120 s of standing after HD using an INVOS 5100c oxygen saturation monitor. The post-HD cerebral rSO2 at rest was 55.8 ± 10.2%, while that at 120 s of standing decreased to 51.9 ± 9.6%; therefore, the percentage change in cerebral rSO2 at 120 s of standing was - 6.8 ± 6.4%, which was significantly lower than before HD (p < 0.001). This change was significantly correlated with the presence of DM, HD duration, mean BP at 120 s of standing, and percentage change in mean BP at 120 s of standing. A multivariable linear regression analysis showed that percentage change in cerebral rSO2 at 120 s of standing was independently associated with the percentage change in mean BP at 120 s of standing (standardized coefficient: 0.432; p = 0.004). Furthermore, there were significant decreases in percentage changes in cerebral rSO2 throughout the standing period in HD patients with versus without DM. Therefore, cerebral oxygenation deterioration upon standing after HD should receive attention, particularly in HD patients with DM.

Cerebral oxygenation and body mass index association with cognitive function in chronic kidney disease patients without dialysis: a longitudinal study.

In chronic kidney disease (CKD) patients, the prevalence of cognitive impairment increases with CKD progression; however, longitudinal changes in cognitive performance remain controversial. Few reports have examined the association of cerebral oxygenation with cognitive function in longitudinal studies. In this study, 68 CKD patients were included. Cerebral regional oxygen saturation (rSO2) was monitored. Cognitive function was evaluated using mini-mental state examination (MMSE) score. Clinical assessments were performed at study initiation and 1 year later. MMSE score was higher at second measurement than at study initiation (p = 0.022). Multivariable linear regression analysis showed that changes in MMSE were independently associated with changes in body mass index (BMI, standardized coefficient: 0.260) and cerebral rSO2 (standardized coefficient: 0.345). This was based on clinical factors with p < 0.05 (changes in BMI, cerebral rSO2, and serum albumin level) and the following confounding factors: changes in estimated glomerular filtration rate, hemoglobin level, proteinuria, salt and energy intake, age, presence of diabetes mellitus, history of comorbid cerebrovascular disease, and use of renin-angiotensin system blocker. Further studies with a larger sample size and longer observational period are needed to clarify whether maintaining BMI and cerebral oxygenation improve or prevent the deterioration of cognitive function.

Association between hepatic oxygenation on near-infrared spectroscopy and clinical factors in patients undergoing hemodialysis.

The hepato-splanchnic circulation directly influences oxygenation of the abdominal organs and plays an important role in compensating for the blood volume reduction that occurs in the central circulation during hemodialysis (HD) with ultrafiltration. However, the hepato-splanchnic circulation and oxygenation cannot be easily evaluated in the clinical setting of HD therapy. We included 185 HD patients and 15 healthy volunteers as the control group in this study. Before HD, hepatic regional oxygen saturation (rSO2), a marker of hepatic oxygenation reflecting the hepato-splanchnic circulation and oxygenation, was monitored using an INVOS 5100c oxygen saturation monitor. Hepatic rSO2 was significantly lower in patients undergoing HD than in healthy controls (56.4 ± 14.9% vs. 76.2 ± 9.6%, p < 0.001). Multivariable regression analysis showed that hepatic rSO2 was independently associated with body mass index (BMI; standardized coefficient: 0.294), hemoglobin (Hb) level (standardized coefficient: 0.294), a history of cardiovascular disease (standardized coefficient: -0.157), mean blood pressure (BP; standardized coefficient: 0.154), and serum albumin concentration (standardized coefficient: 0.150) in Model 1 via a simple linear regression analysis. In Model 2 using the colloid osmotic pressure (COP) in place of serum albumin concentration, the COP (standardized coefficient: 0.134) was also identified as affecting hepatic rSO2. Basal hepatic oxygenation before HD might be affected by BMI, Hb levels, a history of cardiovascular disease, mean BP, serum albumin concentration, and the COP. Further prospective studies are needed to clarify whether changes in these parameters, including during HD, affect the hepato-splanchnic circulation and oxygenation in HD patients.

Muscle mass evaluation using psoas muscle mass index by computed tomography imaging in hemodialysis patients.

BACKGROUND AND AIMS: The use of the psoas muscle mass index (PMI) using computed tomography (CT) has become a marker of interest to evaluate whole body muscle mass. However, in hemodialysis (HD) patients, reports about the clinical significance of psoas muscle evaluation are limited. We aimed to clarify the association between PMI and skeletal muscle mass index (SMI) using bioelectrical impedance analysis (BIA), and to investigate factors affecting PMI in HD patients. METHODS: In this prospective observational study, to evaluate muscle mass, SMI was measured using BIA after HD, and PMI was measured by the manual trace method on routinely available CT scans. PMI measurement was assessed twice by two physicians to compute intra-rater and inter-rater reliability. The correlations between PMI and the clinical factors were evaluated using Pearson's correlation coefficient and a linear regression analysis. Variables with a p-value < 0.05 in the simple linear regression analysis were included in the multivariable linear regression analysis to identify the factors that affected PMI of the HD patients. RESULTS: Fifty HD patients were recruited (31 males and 19 females; HD duration, 9.0 ± 8.8 years). The SMI was 6.10 ± 1.20 kg/m2, and the PMI was 4.79 ± 1.61 cm2/m2. Regarding the reliability of PMI measurements, intra-rater reliability [intra-class correlation (ICC) = 0.999] and inter-rater reliability (ICC = 0.998) were high in this study. The mean PMI of male patients was 5.40 ± 1.62 cm2/m2, while that of female patients was significantly lower (3.78 ± 0.98 cm2/m2; p < 0.001). The PMI was significantly and positively correlated with SMI (r = 0.630, p < 0.001), in addition to HD duration, body mass index (BMI), serum phosphate and serum creatinine (Cr). In the multivariate linear regression analysis by two models using SMI or BMI, they were respectively extracted as an independent factor associating with PMI, in addition to serum Cr and the difference of sex. CONCLUSIONS: PMI assessed with CT positively correlated with SMI measured using BIA. PMI might be one of the methods for evaluating the muscle mass in HD patients, when CT scans are taken as part of routine care.

Polyamine-Rich Diet Elevates Blood Spermine Levels and Inhibits Pro-Inflammatory Status: An Interventional Study.

The Japanese diet and the Mediterranean diet are rich in polyamines (spermidine and spermine). Increased polyamine intake elevated blood spermine levels, inhibited aging-associated pro-inflammatory status (increases in lymphocyte function-associated antigen-1 (LFA-1) on immune cells), suppressed aberrant gene methylation and extended the lifespan of mice. To test the effects of increased polyamine intake by humans, 30 healthy male volunteers were asked to eat polyamine-rich and ready-to-eat traditional Japanese food (natto) for 12 months. Natto with high polyamine content was used. Another 27 male volunteers were asked not to change their dietary pattern as a control group. The volunteers' age of intervention and control groups ranged from 40 to 69 years (median 48.9 ± 7.9). Two subjects in the control group subsequently dropped out of the study. The estimated increases in spermidine and spermine intakes were 96.63 ± 47.70 and 22.00 ± 9.56 µmol per day in the intervention group, while no changes were observed in the control group. The mean blood spermine level in the intervention group gradually rose to 1.12 ± 0.29 times the pre-intervention level after 12 months, and were significantly higher (p = 0.019) than those in the control group. Blood spermidine did not increase in either group. LFA-1 on monocytes decreased gradually in the intervention group, and there was an inverse association between changes in spermine concentrations relative to spermidine and changes in LFA-1 levels. Contingency table analysis revealed that the odds ratio to decrease LFA-1 by increased polyamine intake was 3.927 (95% CI 1.116-13.715) (p = 0.032) when the effect of acute inflammation was excluded. The results in the study were similar to those of our animal experiments. Since methylation changes of the entire genome are associated with aging-associated pathologies and our previous studies showed that spermine-induced LFA-1 suppression was associated with the inhibition of aberrant gene methylation, the results suggest that dietary polyamine contributes to human health and longevity.

Skeletal Muscle Mass Index Is Positively Associated With Bone Mineral Density in Hemodialysis Patients.

Background: Patients with chronic kidney disease (CKD) are at risk for bone loss and sarcopenia because of associated mineral and bone disorders (MBD), malnutrition, and chronic inflammation. Both osteoporosis and sarcopenia are associated with a poor prognosis; however, few studies have evaluated the relationship between muscle mass and bone mineral density (BMD) in hemodialysis (HD) patients. The present study examined the association between skeletal muscle mass index (SMI) and BMD in the lumbar spine and femoral neck in HD patients. Methods: Fifty HD patients (mean age, 69 ± 10 years; mean HD duration, 9.0 ± 8.8 years) in Minami-Uonuma City Hospital were evaluated. BMD was measured by dual-energy X-ray absorptiometry, and SMI was measured by bioelectrical impedance analysis (InBodyTM) after HD. The factors affecting lumbar spine and femoral neck BMD were investigated, and multivariate analysis was performed. Results: In simple linear regression analysis, the factors that significantly affected the lumbar spine BMD were sex, presence of hypertension, presence of diabetes mellitus, body mass index, triglyceride level, grip strength, and SMI; the factors that significantly affected the femoral neck BMD were sex, HD duration, serum creatinine level, tartrate-resistant acid phosphatase 5b level, undercarboxylated osteocalcin (ucOC) level, N-terminal propeptide of type I procollagen level, grip strength, and SMI. In multivariate analysis, SMI (standardized coefficient: 0.578) was the only independent factor that affected the lumbar spine BMD; the independent factors that affected the femoral neck BMD were SMI (standardized coefficient: 0.468), ucOC (standardized coefficient: -0.366) and sex (standardized coefficient: 0.231). Conclusion: SMI was independently associated with the BMD in the lumbar spine and femoral neck in HD patients. The preservation of skeletal muscle mass could be important to prevent BMD decrease in HD patients, in addition to the management of CKD-MBD.

Reperfusion therapy of acute ischemic stroke in an all-in-one resuscitation room called a hybrid emergency room.

Acute ischemic stroke (AIS) caused by major vessel occlusion has potentially poor outcomes. Early successful recanalization after symptom onset is an important factor for favorable outcomes of AIS. We present the case of a 74-year-old man with AIS who underwent the entire process from diagnosis to thrombolysis and endovascular treatment in a hybrid emergency room (ER) equipped with a multidetector computed tomography (CT) scanner and an angiography suite set-up. A hybrid ER can facilitate evaluation and definitive interventions in patients with AIS more quickly and safely and in one place, without the requirement for transfer to a CT scanner or angiography suite set-up. In the present case, the door-to-puncture time and door-to-reperfusion time were 85 and 159 min, respectively, which were shorter than those in the group conventionally treated for stroke in our institution. Further study is needed to confirm the effect of the hybrid ER system.