Risk Classification for Metabolic Syndrome and the Incidence of Cardiovascular Disease in Japan With Low Prevalence of Obesity: A Pooled Analysis of 10 Prospective Cohort Studies.

Background It is uncertain whether risk classification under the nationwide program on screening and lifestyle modification for metabolic syndrome captures well high-risk individuals who could benefit from lifestyle interventions. We examined the validity of risk classification by linking the incidence of cardiovascular disease (CVD). Methods and Results Individual-level data of 29 288 Japanese individuals aged 40 to 74 years without a history of CVD from 10 prospective cohort studies were used. Metabolic syndrome was defined as the presence of high abdominal obesity and/or overweight plus risk factors such as high blood pressure, high triglyceride or low high-density lipoprotein cholesterol levels, and high blood glucose levels. The risk categories for lifestyle intervention were information supply only, motivation-support intervention, and intensive support intervention. Sex- and age-specific hazard ratios and population attributable fractions of CVD, which were also further adjusted to consider non-high density lipoprotein cholesterol levels, were estimated with reference to nonobese/overweight individuals, using Cox proportional hazard regression. Since the reference category included those with risk factors, we set a supernormal group (nonobese/overweight with no risk factor) as another reference. We documented 1023 incident CVD cases (565 men and 458 women). The adjusted CVD risk was 60% to 70% higher in men and women aged 40 to 64 years receiving an intensive support intervention, and 30% higher in women aged 65 to 74 years receiving a motivation-support intervention, compared with nonobese/overweight individuals. The population attributable fractions in men and women aged 40 to 64 years receiving an intensive support intervention were 17.7% and 6.6%, respectively, while that in women aged 65 to 74 years receiving a motivation-support intervention was 9.4%. Compared with the supernormal group, nonobese/overweight individuals with risk factors had similar hazard ratios and population attributable fractions as individuals with metabolic syndrome. Conclusions Similar CVD excess and attributable risks among individuals with metabolic syndrome components in the absence and presence of obesity/overweight imply the need for lifestyle modification in both high-risk groups.

Minimum effective volume of ropivacaine for ultrasound-guided supra-inguinal fascia iliaca compartment block.

Supra inguinal fascia iliaca compartment block (FICB) is increasingly used in elderly patients with hip fractures. However, the minimum effective volume of local anesthetics required for ultrasound-guided supra-inguinal FICB has not been determined. With ethical committee approval and written informed consent from patients, we studied 21 consecutive patients of ASA physical status I-III undergoing surgery for hip fracture who met the inclusion criteria. Blocks were performed before going to the operation room. We determined the injection volumes of 0.25% ropivacaine for consecutive patients from the preceding patient's outcome. The initial volume was 30 ml. The testing interval was set at 10 ml, and the lowest volume was 5 ml. An effective block was defined as loss of sensation of pinprick in the territory of the femoral nerve and lateral cutaneous nerve of the thigh 30 min after the injection. The aim of this study was to determine the 50% effective volume (EV50) and the 95% effective volume (EV95) of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB using Logistic regression analysis. EV50 and EV95 of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB calculated with logistic regression analysis were 15.01 ml (95% confidence interval, 6.53-22.99 ml) and 26.99 ml (95% confidence interval, 20.54-84.09 ml), respectively. EV50 and EV95 of 0.25% ropivacaine for ultrasound-guided supra-inguinal FICB were 15.01 ml and 26.99 ml, respectively.Clinical trial number: UMIN000027277 (URL https://www.umin.ac.jp/ctr/index-j.htm ).

Factors associated with intra-individual visit-to-visit variability of blood pressure in four countries: the INTERMAP study.

Several studies demonstrated that visit-to-visit variability of blood pressure (BP) predicted future events of total death, stroke and cardiovascular disease. Little is known about factors associated with visit-to-visit BP variability in different countries. We recruited participants aged 40-59 years from four countries (Japan, the People's Republic of China [PRC], the United Kingdom [UK] and the United States [US]). At each study visit, BP was measured twice by trained observers using random zero sphygmomanometers after five minutes resting. We defined visit-to-visit BP variability as variation independent of mean (VIM) by using average systolic BP of 1st and 2nd measurement across four study visits. Data on 4680 men and women were analyzed. Mean ± standard deviation of VIM values among participants in Japan, the PRC, the UK and the US were 5.44 ± 2.88, 6.85 ± 3.49, 5.65 ± 2.81 and 5.84 ± 3.01, respectively; VIM value in the PRC participants was significantly higher. Sensitivity analyses among participants without antihypertensive treatment or past history of cardiovascular disease yielded similar results. Higher VIM value was associated with older age, female gender, lower pulse rate and urinary sodium excretion and use of antihypertensive agents such as angiotensin converting enzyme inhibitors, beta blockers and calcium channel blockers. The difference of visit-to-visit BP variability between PRC and other countries remained significant after adjustment for possible confounding factors. In this large international study across four countries, visit-to-visit BP variability in the PRC was higher than in the other three countries. Reproducibility and mechanisms of these findings remain to be elucidated.

Food sources of dietary sodium in the Japanese adult population: the international study of macro-/micronutrients and blood pressure (INTERMAP).

PURPOSE: It is often reported that Na intake levels are higher in Japan than in western countries. Detailed analysis of food intake and its association with Na intake are necessary for supporting further decreases in Na consumption in Japan. We investigated the association between Na and food intake by food group using data from the Japanese participants of the INTERMAP Study. METHOD: Results from the Japanese participants of the INTERMAP Study who did not use antihypertensive medication and/or consume a reduced Na diet were used (531 men and 518 women, aged 40-59 years), obtained from four 24-h dietary recalls and two 24-h urine collections from each participant. We developed a classification system with 46 food group classifications; food consumption and Na intake from these groups were compared across quartiles of participants determined by 24-h urinary Na excretion per unit of body weight (UNa/BW). RESULTS: Average daily Na intake from Japanese high-Na foods was 2552 mg/day. Participants with a higher UNa/BW consumed a significantly greater amount of high-Na Japanese foods, such as salted fish (P = 0.001) and miso soup (P < 0.001). They also had greater amount of rice (P = 0.001). Participants with lower UNa/BW consumed a significantly greater amount of western foods, such as bread (P < 0.001) and milk and dairy products (P < 0.001). CONCLUSIONS: Detailed analyses of various Japanese and western food intakes in addition to Na intake were performed. These results can be used to help draw up effective programs for the reduction in Na intake and prevention of prehypertension/hypertension in the Japanese population.

[A New Teaching Model for Practicing Ultrasound-guided Regional Anesthesia Techniques].

We developed a simulator using "slime" composed of polyvinyl alcohol (PVA) and borax to evaluate this new ultrasound-guided nerve block training model. Seventeen subjects used the training model in the present study. They had no previous experience in performing ultrasound-guided nerve block. A plastic case measuring 25 x 18 x 12 cm was filled with 8 cm of slime. Three pieces of gauze were placed between the slime layers at 2 cm intervals. An in-plane approach was used to visualize the needle for the nerve block, and the amount of time required to stop the needle on the second gauze was measured 5 times for each subject. Significant differences were observed between the times for the first experiment and those for the third experiment to the fifth experiment In the fourth and fifth experiments, all subjects visualized the nerve block needle clearly above the target layer and were able to stop the needle at the target layer. The present simulation using our proposed ultrasound-guided nerve block training model was useful in terms of the amount of time required to perform the procedure and as well as in terms of its safety.

Associations of Serum Isoflavone, Adiponectin and Insulin Levels with Risk for Epithelial Ovarian Cancer: Results of a Case-control Study.

BACKGROUND: The aim of this study was to examine the association of serum isoflavones, adiponectin, and insulin levels with ovarian cancer risk. MATERIALS AND METHODS: We gathered cases with histologically confirmed epithelial ovarian cancer at Sapporo Medical University Hospital from October 2010 to September 2012. Potential controls were recruited from female inpatients without any history of cancer or diabetes mellitus in different wards of the same hospital over the same period of time. Serum isoflavones, adiponectin, and insulin levels were measured in order to estimate associations with ovarian cancer risk in a case-control study. Data from 71 cases and 80 controls were analyzed with a logistic regression model adjusting for known risk factors. RESULTS: A significant reduction in ovarian cancer risk was observed for the high tertile of serum daidzein level versus the low (Ptrend<0.001). A significant reduction in ovarian cancer risk was also observed for the high tertile of serum glycitein level versus the low (Ptrend=0.005). Furthermore, a significant reduction in ovarian cancer risk was observed for the high tertile of serum adiponectin level versus the low (Ptrend=0.004). Conversely, serum insulin level showed significantly elevated risk for ovarian cancer with the high tertile versus the low Ptrend<0.001). CONCLUSIONS: Decreased serum isoflavones levels, such as those for daidzein and glycitein, decreased serum adiponectin levels, and increased serum insulin levels could be shown to be associated with elevated risk of ovarian cancer.

Counts of Slackia sp. strain NATTS in intestinal flora are correlated to serum concentrations of equol both in prostate cancer cases and controls in Japanese men.

BACKGROUND: Isoflavones, which are included in soybeans, have been suggested to protect against prostate cancer. Equol, one of isoflavones, is an intestinally derived bacterial metabolite of daidzein. A newly identified equol-producing bacterium, Slackia sp. strain NATTS, with a high equol-producing activity was isolated from human feces in Japanese adults. Counts of Slackia sp. strain NATTS in intestinal flora have not been assessed with regard to prostate cancer risk. In this study, we investigated the association of serum isoflavones and counts of Slackia sp. strain NATTS with prostate cancer risk in a case-control study. MATERIALS AND METHODS: Concentrations of isoflavones and counts of Slackia sp. strain NATTS in feces were measured from 44 patients with prostate cancer and 28 hospital controls. The risk of prostate cancer was evaluated in terms of odds ratios (ORs) and 95% confidence intervals (CIs) by the logistic regression analysis. RESULTS: The detection proportions of Slackia sp. strain NATTS in cases and controls were 34.1% and 25.0%, respectively. Counts of Slackia sp. strain NATTS were significantly correlated with serum concentrations of equol both in cases and controls (Spearman correlation coefficients, rs=0.639 and rs=0.572, p<0.01, respectively). Serum concentrations of genistein, daidzein, glycitein, and equol were not significantly associated with risk of prostate cancer. CONCLUSIONS: This study found that counts of Slackia sp. strain NATTS correlated with serum concentrations of equol both in prostate cancer cases and controls, but serum isoflavone concentrations were not associated with risk of prostate cancer in our patients.

[Case of ulnar nerve palsy in a patient with a history of total elbow arthroplasty after abdominal surgery under general anesthesia].

Ulnar nerve palsy is a well recognized complication of the general anesthesia. We experienced a case of ulnar nerve palsy after abdominal surgery under general anesthesia in a patient with a history of total elbow arthroplasty and ulnar nerve translocation. It appears that pressure on medial epicondyle caused the palsy and that the position of the ulnar nerve has to be carefully examined before surgery in a patient with a history of total elbow arthroplasty and ulnar nerve translocation.

Increased serum apolipoprotein B48 concentration in patients with metabolic syndrome.

AIM: Postprandial hyperlipidemia is characterized by an increase of chylomicron remnants (CM-R), and is a risk factor for atherosclerosis. Apolipoprotein (apo) B48 exists exclusively in chylomicroms and CM-R, and fasting plasma levels of apo B48 may reflect high postprandial levels of chylomicrons and/or CM-R. We hypothesized that fasting apo B48 levels may be increased in metabolic syndrome. METHODS: We investigated 1,349 inhabitants (528 men and 821 women aged 62.4+/-12.8 y; mean+/-S.D.) of two towns in rural Hokkaido, who underwent health checks in 2005. RESULTS: The fasting apo B48 level was significantly higher in males than females (geometric mean 1.92; 95% CI 1.802.04 microg/mL, vs. 1.69; 95% CI 1.611.76 microg/mL; p< 0.001). Ln (apo B48) showed a significant positive correlation with total cholesterol and ln (triglycerides), and a negative correlation with HDL-cholesterol. The correlation between ln (apo B48) and ln (triglycerides) was strong. Apo B48 was significantly higher in men and women with than without metabolic syndrome. Regression analysis revealed that ln (apo B48) was significantly associated with age, BMI, total cholesterol, HDL cholesterol, LDL cholesterol, and ln (triglyceride). CONCLUSION: Fasting apo B48 levels are raised in individuals with metabolic syndrome.

Relationship between hepatocellular carcinoma and impaired glucose tolerance among Japanese.

BACKGROUND/AIMS: Both the incidence of diabetes mellitus (DM) and mortality from Hepatocellular carcinoma (HCC) are increasing in Japan. As the association of overall cancer and HCC with impaired glucose tolerance (IGT) has been studied rarely in the world including Japan, this study assessed their associations using cohort data of Hokkaido, Japan. METHODOLOGY: After getting ethical consent, this study included 908 men and 1,081 women aged 30-77 years during 1977-78 and collected detailed information using the baseline survey. The subjects were followed until 2002 and deaths were recorded using ICD-9. Classifying them into three groups of diabetes status namely DM, IGT, and normal, the relative risk (RR) of mortality was estimated by diabetes status using multivariate Cox model. RESULTS: This study revealed no association between overall cancer and diabetes status. However, the RR of mortality from HCC was about 11 times (HR= 10.8, 95%CI: 1.3-92.5) higher in IGT compared with normal group. DM group also showed higher risk of mortality than normal group. CONCLUSIONS: HCC mortality was significantly high among IGT group. However, as the results of the study were based on small data, further studies with large cohort are needed to address the association of IGT with overall cancer and HCC mortality in Japan.

[Pain control with epidural anesthesia for uterine artery embolization].

BACKGROUND: To reduce the severity of post procedure pain associated with uterine artery embolization (UAE) for leiomyomata, we used continuous infusion of low concentration ropivacaine through an epidural catheter. METHODS: Thirteen patients for UAE were evaluated. In a patient without indication for epidural anesthesia, the pain was controlled with intermittent morphine infusion. Other patients had post procedure pain managed with 10 ml bolus of 1% lidocaine and continuous infusion of 0.2% ropivacaine at 5 ml x hr-1 for 16 hours. RESULTS: The patient complained of severe pain just after UAE and required epidural lidocaine. Then, we started to infuse lidocaine or ropivacaine just before starting UAE. Among these cases, 9 patients required extra pain control using NSAIDs as a rescue. Only three patients required no medication except epidural analgesia. CONCLUSIONS: Continuous infusion of 0.2% ropivacaine at a rate of 5 ml x hr-1 is not enough for pain management after UAE.

Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma.

BACKGROUND: We investigated the advantages of intraoperative transesophageal echocardiography (TEE) during inferior vena caval tumor thrombectomy in renal cell carcinoma (RCC). METHODS: Five patients with RCC that extended into the inferior vena cava (IVC) underwent radical nephrectomy. To remove the tumor thrombus in the IVC, an inflated Fogarty balloon catheter was used to pull the thrombus below the level of the hepatic veins with real-time TEE monitoring. RESULTS: In all cases, TEE monitoring during surgery provided an accurate and excellent view of the IVC thrombus. TEE was particularly helpful for the thrombectomy to minimize hepatic mobilization by using occlusion balloon catheter in two patients whose thrombus extended to the intrahepatic IVC. CONCLUSIONS: Intraoperative real-time TEE monitoring is a safe, minimally invasive technique that can provide accurate information regarding the presence and extent of IVC involvement, guidance for placement of a vena caval clamp, confirmation of complete removal of the IVC thrombus and intervention using catheters to assist in thrombectomy.