Background: Patients with idiopathic normal pressure hydrocephalus (iNPH) may be more prone to all fracture types due to falls. Vertebral compression fractures (VCFs) are a global burden that temporarily or permanently affects millions of elderly people. This study aimed to investigate the prevalence of iNPH in patients with VCFs. Methods: We retrospectively reviewed 128 patients aged 60–102 years who underwent balloon kyphoplasty (BKP) for VCFs between November 1, 2017, and March 31, 2020. We also assessed the presence of the iNPH triad (i.e., gait disturbance, cognitive impairment, and urinary incontinence). Patients with Evans’ index (EI) >0.3 and the iNPH triad were defined as having possible iNPH, those with clinical improvement after a cerebrospinal fluid tap test were defined as having probable iNPH, and those with clinical improvement after a shunt surgery were defined as having definite iNPH. Results: Of the 128 patients, seven were excluded due to a history of intracranial disease that could cause ventricular enlargement or gait disturbance. Another 70 patients who did not undergo head computed tomography or magnetic resonance imaging one year before or after BKP were excluded from the study. Finally, 51 patients with a mean age of 78.9 years were enrolled. The mean EI value of these 51 patients was 0.28, with 18 patients showing EI >0.3. Moreover, 18 had possible iNPH, one had probable iNPH, and one had definite iNPH. Conclusion: Screening for iNPH in elderly patients with VCFs can allow early diagnosis of iNPH and benefit them more from surgical treatment.

Hundreds of thousands of people living along the Yatsushiro Sea coast have been exposed to methylmercury from the contaminated water of the Chisso factory in Minamata. The most common neurological disorder caused by methylmercury is somatosensory disturbance, but very few studies have been conducted in the world to determine its pathophysiology and origin, including the Japanese cases, which have produced numerous intoxicated individuals. We have already shown in previous studies the body part where the disorder occurs and that its cause is not peripheral nerve damage but damage to the parietal lobes of the cerebrum. We reanalyzed the results of subjective symptoms, neurological findings, and quantitative sensory measurements in 197 residents (63.2 ± 10.7 years old) from contaminated areas exposed to methylmercury from seafood and 130 residents (63.7 ± 9.3 years old) from control areas, the same subjects as in previous studies, to determine the characteristics of somatosensory disturbance in detail. The most commonly affected sensory modalities were superficial peripheral touch and pain in the extremities, followed by two-point discrimination and deep senses, and in the most severe cases, full-body sensory dysfunction and impairment of all sensory submodalities. The severity of sensory submodalities correlated with each other but not with peripheral nerve conduction test indices, further confirming the correctness of our assertion about the responsible foci of sensory disturbance. The health effects of chronic methylmercury toxicosis can be elucidated by a detailed examination of sensory deficits.

Abstract Background In the clinical setting, ischemic heart disease (IHD) is a major problem not only in general patients but also in regular hemodialysis (HD) patients. 13N-ammonia positron emission tomography (13NH3PET) is an established and excellent diagnostic test for IHD. We have reported about the predictability of coronary flow reserve (CFR) in poor prognosis in HD population. Some prior studies show that low CFR predicts poor prognosis for not only cardiovascular event but also all-cause mortality. Although it is well-known that CFR is an important predictor, there are limited data about predictability of CFR for non-cardiovascular (non-CV) mortality. We investigated the prognostic predictability of all-cause mortality, cardiovascular (CV) mortality and non-CV mortality. Methods In total 1020, patients who underwent NH3+PET suspected of ischemic heart disease from May 2013 to May 2022 were included. They are divided into two groups according to CFR cut off value (CFR=2.0). 465 patients were included into low CFR group and 555 patients were included into high CFR group. We collected all-cause mortality, cardiovascular (CV) mortality and non-CV mortality. CV mortality was defined death from myocardial infarction, sudden death, stroke, heart failure, arrhythmia and ischemic colitis. We have followed them in 1282 days (median, 1st-3rd quartile was 510-2116). Results We found any cause death were 285 cases (the high CFR group vs the low CFR group; 165 (35.5%) vs 118 (21.3%), p<0.001), CV death were 121 cases (52 (9.4%) vs 68 (14.6%), p=0.010) and non-CV death were 164 cases (66(11.9%) vs 97 (20.9%, p<0.001)). Kaplan-Meier curve analysis and Cox regression model shows the low CFR groups shows poor prognosis for all-cause mortality (log rank; p<0.001, hazard ratio (HR); 1.9964, 95% confidential interval (CI); 1.576-2.529), CV mortality (log rank; p=0.0009, HR; 1.834, 95%CI; 1.278-2.633) and non-CV mortality (log rank; p<0.0001, HR; 2.213, 95%CI; 1.555-2.907). Furthermore, multivariate cox regression model shows the continuous value of CFR is an independent predictor for both all-cause mortality (HR0.180, 95%CI 0.074-0.435, p=0.0001) and non-CV mortality (HR0.553, 95% CI0.397-0.769, p=0.0004). Conclusion In dialysis population, CFR is an important predictor for all-cause mortality, CV mortality and non-CV mortality. In addition, CFR would predict non-CV death in HD population even though CFR is an index for IHD.

Abstract Background Although lower extremity revascularization has been commonly performed in chronic hemodialysis (HD) patients with peripheral artery disease (PAD), poorer prognosis after revascularization still remains major problems. Recently, protein-energy wasting (PEW) or malnutrition have been considered to be strongly associated with chronic inflammation and advanced atherosclerosis in HD patients. We investigated the association of geriatric nutritional risk index (GNRI) as a surrogate marker of the PEW, C-reactive protein (CRP) and their joint role with prediction of amputation and/or mortality after lower extremity revascularization in HD patients. Method We enrolled a total of 800 HD patients (age 67±10 years, diabetes 63.3% and critical limb ischemia 52.9%) who successfully underwent lower extremity revascularization [535 with endovascular therapy (EVT) and 265 with bypass surgery]. Patients were divided into tertiles according to pre-procedural GNRI levels; tertile 1 (T1): <88.1, T2: 88.1-96.7and T3: >96.7, and CRP levels; T1: <2.0mg/l, T2: 2.0-12.6mg/l and T3: >12.6mg/l, respectively. Primary outcome was amputation-free survival (AFS). They were followed up for up to 8 years. Results During follow-up period (median: 43 months), 56 (7.0%) patients needed major amputation and 183 (22.9%) patients died. Kaplan-Meier analysis shows that the AFS rates for 8 years were 47.0%, 56.9% and 69.5% in T1, T2 and T3 of GNRI, and were 65.8%, 58.7% and 33.2% in T1, T2 and T3 of CRP, respectively (p<0.0001 in both). After adjustment for male, age, previous coronary artery disease, procedure (EVT vs. bypass surgery), below-knee artery disease and ulcer/gangrene as covariates with p<0.05 by univariate analysis, declined GNRI [hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.57-3.07, p<0.0001 for T1 vs. T3] and elevated CRP (HR 1.78, 95%CI 1.24-2.59, p=0.0016 for T3 vs. T1) were identified as independent predictors of amputation and/or mortality. In the combined setting of both variables, the risk of amputation and/or mortality was 3.77-fold higher (95%CI 1.97-7.69, p<0.0001) in the group with T1 of GNRI and T3 of CRP than in that with T3 of GNRI and T1 of CRP (Figure). Addition of GNRI and CRP in a predicting model with established risk factors improved C-statistics (0.661 to 0.716, p=0.0021) greater than that of each alone. Conclusion Among HD patients undergoing lower extremity revascularization for PAD, those with pre-procedural declined GNRI and elevated CRP frequently experienced amputation and/or mortality, furthermore, combination of both variables could more accurately stratify the risk of amputation and/or mortality.

Abstract Background Ischemic heart disease (IHD) is still a major problem not only in general patients but also in regular hemodialysis (HD) patients. We have reported about prognostic value of coronary flow reserve (CFR) derived from N13-ammonia PET in HD population for all-cause mortality and major adverse cardiac event (MACE) in prior studies. We investigated the impact of diabetes and low CFR on the mortality in HD population. Methods A total 1,027 HD patients who undergone 13N-ammonia PET for suspected IHD were enrolled. We divided them into four groups according to CFR (cut off value = 2.0) and whether DM or not. We collected and evaluated their all-cause mortality, cardiovascular (CV) mortality and MACE, and analyzed using Kaplan-Meier methods and uni/multivariate cox regression model. Results The number of DM with better CFR group was 194, DM with worse CFR was 244, non-DM with better CFR was 361 and non-DM with worse CFR was 221. We found 285 case of all-cause mortality, 121 case of CV mortality, 164 case of CV mortality and 424 case of MACCE. Whether DM or not, CFR predicts HD patients’ prognosis precisely (See figure). Furthermore, multivariate Cox regression model showed CFR (continuous value) was an independent predictor for all-cause mortality (hazard ratio (HR); 0.774, 95% confidential interval (CI) 0.606-0.979, p value=0.037) and MACCE (HR0.769, 95%CI0.630-0.932, p=0.009) in DM and HD population. Furthermore, CFR predicted all-cause mortality (HR0.731, 95%CI 0.569-0.940, p=0.015) and non-CV death (HR0.636, 95%CI0.451-0.896, p=0.010) in non-DM and HD population. Conclusion The HD patients with DM and low CFR had worst prognosis in all-cause mortality, CV death, non-CV death and MACCE.

Background: There is ongoing debate on whether continuous deep sedation (CDS) for psycho-existential suffering is appropriate. Objective: We aimed to (1) clarify clinical practice of CDS for psycho-existential suffering and (2) assess its impact on patients' survival. Methods: Advanced cancer patients admitted to 23 palliative care units in 2017 were consecutively enrolled. We compared patients' characteristics, CDS practices, and survival between those receiving CDS for psycho-existential suffering ± physical symptoms and only for physical symptoms. Results: Of 164 patients analyzed, 14 (8.5%) received CDS for psycho-existential suffering ± physical symptoms and only one of them (0.6%) solely for psycho-existential suffering. Patients receiving CDS for psycho-existential suffering, compared with those only for physical symptoms, were likely to have no specific religion (p = 0.025), and desired (78.6% vs. 22.0%, respectively; p < 0.001) and requested a hastened death more frequently (57.1% vs. 10.0%, respectively; p < 0.001). All of them had a poor physical condition with limited estimated survival, and mostly (71%) received intermittent sedation before CDS. CDS for psycho-existential suffering caused greater physicians' discomfort (p = 0.037), and lasted for longer (p = 0.029). Dependency, loss of autonomy, and hopelessness were common reasons for psycho-existential suffering that required CDS. The survival time after CDS initiation was longer in patients receiving it for psycho-existential suffering (log-rank, p = 0.021). Conclusion: CDS was applied to patients who suffered from psycho-existential suffering, which often associated with desire or request for a hastened death. Further studies and debate are warranted to develop feasible treatment strategies for psycho-existential suffering.

Vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) causes serious neurological complications, despite surgical clipping of the aneurysm. Intrathecal urokinase (UK) infusion has been shown to effectively prevent symptomatic vasospasm in patients who have undergone endovascular obliteration of the ruptured aneurysms. To investigate whether intrathecal UK infusion can prevent symptomatic vasospasm in patients undergoing surgical or endovascular treatment. A total of 90 patients with severe aneurysmal SAH were enrolled and assigned to a surgical neck clipping (n= 56) or an endovascular coil embolization (n= 34) groups. After treatment, UK infusion from the lumbar drain was repeated in 32 patients in the surgical neck clipping group (group B) and all in the endovascular coil embolization group (group C) until complete resolution of the SAH was observed on computed tomography. The remaining 24 of the surgical neck clipping group, without UK infusion, were assigned to group A. Symptomatic vasospasm occurred in 7 (29.2%) patients in group A, 2 (6.3%) in group B, and none in group C (group A vs. group B [P=0.02]; group B vs. group C [P=0.14]). Excellent clinical outcomes (modified Rankin score, 0 or 1) were observed in 37.5%, 59.4%, and 76.5% of patients in group A, B, and C, respectively (group A vs. group B [P=0.11]). Clearance of SAH via intrathecal UK infusion significantly reduced symptomatic vasospasm in patients in both UK groups, resulting in better clinical outcomes.

This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.

The number of patients on antithrombotic drugs for coronary heart disease or cerebrovascular disease has been increasing with the aging of society. We occasionally need to decide whether to continue or discontinue antithrombotic drugs before spine surgery. The purpose of this study is to understand the current perioperative management of antithrombotic drugs before elective spine surgery in Japan. In 2021, members of the Japanese Society for Spine Surgery and Related Research (JSSR) were asked to complete a web-based questionnaire survey that included items concerning the respondents' surgical experience, their policy regarding discontinuation or continuation of antithrombotic drugs, their reasons for decisions concerning the management of antithrombotic drugs, and their experience of perioperative complications related to the continuation or discontinuation of these drugs. A total of 1,181 spine surgeons returned completed questionnaires, giving a response rate of 32.0%. JSSR board-certified spine surgeons comprised 75.1% of the respondents. Depending on the management policy regarding antithrombotic drugs for each comorbidity, approximately 73% of respondents discontinued these drugs before elective spine surgery, and about 80% also discontinued anticoagulants. Only 4%-5% of respondents reported continuing antiplatelet drugs, and 2.5% reported continuing anticoagulants. Among the respondents who discontinued antiplatelet drugs, 20.4% reported having encountered cerebral infarction and 3.7% reported encountering myocardial infarction; among those who discontinued anticoagulants, 13.6% reported encountering cerebral embolism and 5.4% reported encountering pulmonary embolism. However, among the respondents who continued antiplatelet drugs and those who continued anticoagulants, 26.3% and 27.2%, respectively, encountered an unexpected increase in intraoperative bleeding, and 10.3% and 8.7%, respectively, encountered postoperative spinal epidural hematoma requiring emergency surgery. Our findings indicate that, in principle, >70% of JSSR members discontinue antithrombotic drugs before elective spine surgery. However, those with a discontinuation policy have encountered thrombotic complications, while those with a continuation policy have encountered hemorrhagic complications.

Introduction Challenges are often observed during care transitions from home to hospital among frail elderly individuals who tend to be treated by different providers. This study evaluated the effectiveness of early care information transfer on the quality of care transitions among home-dwelling elderly patients in Japan who needed acute hospitalization. Methods A cluster randomized controlled trial with a clinic as a clustering unit was conducted with patients aged 65 years and older who had home-visit care and then needed to be hospitalized for acute care. The main outcomes were the quality of care transition perceived by the patient, measured by a self-administered questionnaire, and patient satisfaction, measured by the Hospital Patient Satisfaction Questionnaire. Multilevel regression analysis was used to adjust for clustering and covariates. Results Among 177 patients (78 patients in the intervention group vs. 99 patients in the control group) from 17 clinics (8 vs. 9 clinics) who were admitted to hospitals during the study period, 112 patients with main outcomes were included in the analysis (45 patients vs. 67 patients). Quality of care transition was not statistically significantly different between groups (understanding of home care situations: 58.8 vs. 58.2, p = 0.88; preference on where to be cared for: 58.1 vs. 59.6, p = 0.67; goal for discharge: 71.9 vs. 70.9, p = 0.79; care coordination: 66.3 vs. 63.8, p = 0.56). Discussion Early care referral in care transition did not show effectiveness in the quality of care transition and patient satisfaction. Studies on information-sharing in the care transition from home to hospitals are needed.