Journal of Nippon Medical School最新文献

MicroRNA (miRNA) is a small RNA molecule that does not code for proteins, and organ- and disease-specific miRNAs are being investigated as diagnostic tools and therapeutic targets, particularly for cardiovascular disease and cancer. Much remains unknown about how anesthetics, other drugs, and perioperative management affect miRNAs, but miRNA-targeted drugs might eventually be used perioperatively. This review examines changes in miRNA expression related to anesthesia management. Sevoflurane results in gene expression patterns that differ by organ. The author investigated changes in miRNA expression induced by anesthetics in the brain, lungs, and liver and found that changes in miRNA expression differ by drug and organ. Since miRNA does not have a one-to-one correspondence with its target mRNA and exhibits complex effects within and between cells, as well as remotely, drug- and organ-specific changes in mRNA expression caused by anesthetics likely involve complex alterations. Cardiovascular disease and cancer are related to perioperative management via miRNAs. Inhalational anesthetics may exacerbate or suppress cellular activity, depending on the type of cancer, and the mechanisms of action differ depending on the inhalational anesthetic. These findings suggest that propofol is more likely to contribute to suppression of cancer cells through intercellular communication. The role of miRNA in perioperative management remains unclear. In the future, it is expected that changes in miRNA expression will be considered when selecting and administering anesthetic drugs perioperatively.

Informed consent (IC) is closely related to shared decision making (SDM), and SDM can lead to IC. IC is fundamental to medical ethics as described in the Geneva, Helsinki, and Lisbon declarations and is essential for clinical practice, as it provides legal protection for healthcare professionals. IC should be achieved through SDM based on both narrative-based medicine and evidence-based medicine. SDM should also involve healthcare professionals other than physicians (e.g., nurses, pharmacists, social workers). Communication skills for IC are important and are encapsulated in the SPIKES protocol. IC for breast cancer treatment requires explanation of the roles of local and systemic therapy. A documented "do not attempt resuscitation" order should be obtained for end-of-life IC.

The Oikawa-Nagao (ON) mouse is a polygenic animal model of type 2 diabetes and obesity developed by selective breeding of mice with inferior glucose tolerance [diabetes-prone (ON mouse DP^®; ON-DP) strain] and superior glucose tolerance [diabetes-resistant (ON mouse DR^®; ON-DR) strain]. Hybrid mice of three different inbred strains (C57BL/6, AKR, and AKR) were fed a high-fat diet and then selectively bred for higher and lower post-challenge blood glucose levels in oral glucose tolerance tests over 20 generations. Compared to ON-DR mice, ON-DP mice were found to be predisposed to develop obesity and diabetes after being fed a high-fat diet. Our recent studies suggest that the emergence of these phenotypes is associated with novel pathophysiology of type 2 diabetes and obesity, such as low insulin secretion capacity associated with high CD36 expression in pancreatic β-cells and hypoleptinemia preceding obesity due to low leptin secretion capacity in adipocytes. In addition, it has been suggested that ON-DP mice fed an atherogenic diet are a suitable model to reproduce atherosclerotic lesion formation due to fluctuations in blood glucose levels. This may facilitate the elucidation of mechanisms underlying diabetic macrovascular complications. This review will present the development strategy of the ON mouse strain, representative metabolic phenotypes and their underlying mechanisms. Furthermore, their relevance to the pathophysiology of type 2 diabetes and obesity in humans will be discussed.

Background: Perioperative prophylactic antimicrobials are re-administered at intervals of twice their half-life. However, the actual concentrations of antimicrobial agents and the degree of elevation remain unelucidated.

Methods: This prospective cohort study was conducted at a single tertiary care center. Serum concentrations were evaluated in patients who underwent hepatobiliary-pancreatic surgery between April 2019 and December 2020 and received an additional dose of flomoxef (FMOX) every 3 h or 5 h during the surgical procedure based on their renal function.

Results: Among the 31 participants, 25 and six received FMOX every 3 h and 5 h, respectively. Analysis based on renal function revealed median FMOX concentrations of 9.88 mg/L and 9.85 mg/L (p = 0.09) for patients with creatinine clearance (Ccr) >60 mL/min and 14.26 mg/L and 20.03 mg/L (p = 0.02) for the patients with Ccr ≤60 mL/min at 3 h and 6 h, respectively, with notable elevation at Ccr ≤60 mL/min. Moreover, the serum FMOX concentration at 6 h for the 3-h dosing patients with Ccr ≤60 mL/min was significantly higher than the concentration at 5 h for the 5-h dosing patients with Ccr ≤60 mL/min (20.03 mg/L vs. 12.85 mg/L, p = 0.04). Although serum concentrations at 3-h and 6-h intervals did not differ significantly in patients with Ccr ≥60 mL/min, these significantly increased in patients with Ccr <60 mL/min.

Conclusions: Administering FMOX every 3 h when Ccr is ≥60 mL/min and every 5 h when Ccr is <60 mL/min are appropriate.

Background: Role-playing is a key learning method in genetic counseling education, with facilitators playing a crucial role. Although facilitator training exists in other fields, it lacks a structured framework in the context of genetic counseling. Identifying the factors contributing to facilitator success can improve the quality of education. This study aims to examine the key factors associated with successful experiences as genetic counseling facilitators.

Methods: An anonymous cross-sectional survey was conducted in September 2023 among 356 members of the Japanese Association of Certified Genetic Counselors.

Results: A total of 106 responses (29.7%) were collected, with 45 participants (42.4%) possessing facilitator experience. Logistic regression analysis identified prior learning experiences (OR = 10.02, 95% CI: 1.07-93.7) and confidence as a facilitator (OR = 25.94, 95% CI: 2.27-295.96) as significant factors for successful facilitation. Prior learning experiences correlated with observing inappropriate facilitation (OR = 6.39, 95% CI: 1.25-32.76). Confidence was linked to both skill improvement opportunities (OR = 14.30, 95% CI: 1.41-145.14) and inappropriate facilitation (OR = 9.65, 95% CI: 1.67-55.67).

Conclusion: Successful facilitator experiences were associated with prior learning and confidence. Inappropriate facilitation played an indirect role in facilitator success. Enhancing confidence through learning opportunities and exposure to facilitation challenges is crucial for facilitator development.

Background: Remimazolam is an ultrashort-acting benzodiazepine that maintains stable hemodynamics during anesthesia. However, few reports have focused on hemodynamic stability and opioid use during cardiac surgery with remimazolam. We hypothesized that administration of remimazolam for induction and maintenance of anesthesia for transcatheter aortic valve implantation would maintain hemodynamics as effectively as conventional anesthetics and allow use of an appropriate dose of opioids. We compared intraoperative hemodynamics and opioid use in patients with severe aortic stenosis who received remimazolam or conventional anesthetics.

Methods: This retrospective cohort study analyzed data for patients who underwent transcatheter aortic valve implantation from October 2022 to September 2023. The 23 patients were divided into two groups: a remimazolam group and midazolam + sevoflurane group. The primary outcome was intraoperative blood pressure. The secondary outcomes were the doses of vasoconstrictors, vasodilators, and opioids used.

Results: There was no significant difference in any patient characteristic or intraoperative blood pressure between the two groups (before anesthesia: 92.0 [87.0-99.8] vs. 91.0 [86.0-107.0] mm Hg, P=0.935; 1 minute after induction of anesthesia: 91.0 [83.0-98.5] vs. 90.0 [86.3-95.3] mm Hg, P=0.843; at the start of surgery: 77.0 [70.0-79.0] vs. 82.5 [75.5-105.5] mm Hg, P=0.072; at the end of surgery: 74.0 [71.0-78.0] vs. 82.5 [75.5-90.8] mm Hg, P=0.082). The maximum rate of remifentanil administration was significantly higher in the remimazolam group (0.10 [0.10-0.20] vs. 0.10 [0.013-0.10] μg/kg/min, P=0.012).

Conclusions: Remimazolam maintained hemodynamics as effectively as midazolam + sevoflurane, even when used in combination with opioids. Remimazolam thus appears to be noninferior to midazolam + sevoflurane.

Background: Diagnosis of bone metastases would be hastened if they could be detected on plain radiographs obtained at the first visit to an orthopedic surgeon. However, lesions are often undetectable on plain radiography. Bone metastasis is diagnosed at the first visit in only a few patients, and diagnosis is delayed in many cases. We investigated the diagnostic performance of plain radiography that used a new image processing method, Dynamic Visualization II (DV), to diagnose bone metastases.

Methods: We enrolled 29 patients with symptomatic pelvic bone metastases who visited our hospital between April 2018 and March 2021. The evaluation images were created by processing the original plain radiography data with the default settings for DV (Presets 1-4). Processing with Preset 1 resulted in an image converted to conventional film parameters, whereas Presets 2-4 utilized different DV processing methods. The readers were six orthopedic trainees, and the reading time was 30 seconds per image. The rate of correct answers for images processed with Preset 1 was compared to the rates for those processed with the other presets. Additionally, the rate of correct answers was analyzed in relation to clinical variables.

Results: The correct answer rate was significantly higher for Preset 3 (43.7%) and Preset 4 (42.5%) than for Preset 1 (28.7%). Correct answer rates for Presets 3 and 4 were significantly higher for elderly patients, male patients, patients with innominate bone lesions, patients with osteolytic bone metastases, and patients with a normal body weight.

Conclusions: Image processing by DV improved diagnosis of bone metastases by plain radiography. DV might hasten diagnosis of bone metastases and help prevent associated complications.

Background: We evaluated the effects of drug therapy on T lymphocyte subsets and their associations with recurrent chronic bronchitis (CB) attacks.

Methods: A total of 162 CB patients treated from April 2020 to April 2021 were selected. All patients underwent anti-infective, cough-relieving, and phlegm-eliminating treatment, as detailed in Clinical Pathway for Chronic Bronchitis. They were divided into a recurrent attack group (n=95) and a non-recurrent attack group (n=67). Changes in T lymphocyte subsets at different time points of treatment and their associations with the number of attacks were analyzed. Associated factors were analyzed in a multivariate logistic regression model, and their predictive value was validated using a nomogram prediction model and receiver operating characteristic (ROC) curves.

Results: The number of attacks at 1 year after treatment was positively correlated with CD8⁺ and negatively correlated with CD3⁺, CD4⁺, and CD4⁺/CD8⁺. A history of smoking, CD3⁺, CD4⁺, CD8⁺, and CD4⁺/CD8⁺ were independent risk factors for recurrent attacks. The nomogram prediction model showed that the total risk value corresponding to smoking history, low CD3⁺, CD4⁺, and CD4⁺/CD8⁺, and elevated CD8⁺ was 0.86, and the concordance index and area under the ROC curve of the model was 0.896 (95% CI: 0.782-0.997, P<0.05) and 0.816 (95% CI: 0.803-0.847, P<0.001), respectively. There was an association between T lymphocyte subsets and recurrent attacks before and after treatment of CB.

Conclusions: Low CD3⁺, CD4⁺/CD8⁺ and CD4⁺, elevated CD8⁺, and smoking history were risk factors for recurrent attack.

Background: Information is limited on the incidence and risk factors for further serious conditions after an in-hospital fall. Using data from the incident-accident reports, we assessed the incidence and risk factors for subsequent adverse events (SAEs) among outpatients after in-hospital falls.

Methods: Incident-accident reports from April 2017 to March 2024 at Nippon Medical School Tama Nagayama Hospital were reviewed to identify outpatient falls. Data on patient characteristics and fall-related details were collected. Multivariable logistic regression analysis was performed to identify risk factors for SAEs.

Results: We analyzed data from 118 outpatients with in-hospital falls (mean age: 76.4±11.7 years; male: 56.8%): 39 (33.1%) experienced SAEs, including 5 fractures (4.2%), 13 functional disorders (11.0%), 17 surgical procedures (14.4%), and 17 admissions (14.4%). Multivariable analysis showed that males had a significantly higher odds ratio (OR) for SAEs than females, even after adjusting for age (OR, 2.80; 95% CI, 1.21-6.48; P=0.016). For each SAE, the floor of the fall, number of previous falls, and site of the fall were significantly associated with a subsequent fracture, functional disorder, and surgical procedure after an in-hospital fall, respectively.

Conclusions: The incidence rate of SAEs among outpatients with in-hospital falls was 33.1%. Male sex was the only significant risk factor for SAEs, and factors contributing to individual SAE types were distinct. To prevent further adverse outcomes after in-hospital falls, medical staff should pay more attention to patients with these risk factors.