Emergency management of pediatric epileptic seizures in non-hospital settings in Japan.

OBJECTIVE: To assess the current management of pediatric epileptic seizures in non-hospital settings and the efficacy of early therapeutic intervention with rescue medication in Japan. METHODS: This descriptive cross-sectional study was based on an online survey of caregivers of pediatric patients with epilepsy. The survey consisted of questions regarding seizure frequency and symptoms, the use of rescue medication, and emergency medical care. Statistical analyses were performed to evaluate the association between the time to rescue medication administration and seizure resolution. RESULTS: Responses were obtained from 1147 caregivers of pediatric patients with epilepsy. Of the patients described in the study, 98.5 % had been prescribed anti-seizure medication, 95.3 % had more than a few seizures per year, and 90.3 % used rescue medication. The time to seizure resolution was significantly reduced when rescue medication was administered early. Overall, 28.4 % of the patients required emergency transport to hospital, which increased disruption to the lives of caregivers, who returned to their normal activities after an average of 17.2 h. CONCLUSION: Emergency transport of patients places a significant burden on caregivers. Earlier administration of rescue medications is associated with a reduction in the need for emergency room visits, which reduces the burden on the patient as well as the caregiver.

Risk of hospitalized infections in older elderly patients with rheumatoid arthritis treated with tocilizumab or other biological/targeted synthetic disease-modifying antirheumatic drugs: Evaluation of data from a Japanese claims database.

OBJECTIVE: We compared the incidence rates of hospitalized infections (HIs) between tocilizumab (TCZ) and other biological/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in adults aged ≥75 years with rheumatoid arthritis (RA). METHODS: We used a Japanese claims database from Medical Data Vision Co., Ltd (Tokyo, Japan) to perform a retrospective longitudinal population-based study in patients with RA who were prescribed b/tsDMARDs between 2014 and 2019. We calculated adjusted risk ratios (aRRs) for HIs in three age groups (<65, ≥65 and <75, and ≥75 years). RESULTS: Of 5506 patients, 2265 (41.1%) were <65 years, 1709 (31.0%) were 65-74 years, and 1532 (27.8%) were ≥75 years. Crude incidence rates (/100 person-years) of HIs were 3.99, 7.27, and 10.77, respectively. In the oldest group, aRRs (95% confidence interval) for HIs (b/tsDMARDs versus TCZ) were as follows: etanercept, 2.40 (1.24-4.61); adalimumab, 1.90 (0.75-4.83); golimumab, 1.21 (0.66-2.23); and abatacept, 0.89 (0.49-1.62). In the other age groups, the noticeable difference was a lower aRR of etanercept versus TCZ in the youngest group (0.30, 0.11-0.85). CONCLUSION: In patients with RA aged ≥75 years, b/tsDMARDs have a similar risk of HIs to tocilizumab except for etanercept.

Benefits of Working from Home During the COVID-19 Pandemic for Undiagnosed Workers with Attention-Deficit/Hyperactivity Disorder Symptoms.

Purpose: Our previous study suggested that working conditions might impact work productivity amid the COVID-19 pandemic. This study aimed to investigate the association between working from home (WFH) and depressive symptoms, work productivity, and quality of life (QOL), in undiagnosed workers with attention-deficit/hyperactivity disorder (ADHD) symptoms during the COVID-19 pandemic. Methods: During the pandemic, the survey was conducted among eligible workers with (N = 904) and without (N = 900) ADHD symptoms based on the Adult ADHD Self-Report Scale [ASRS]. Each group was further stratified by working conditions (full working on-site [FWOS], hybrid, full WFH [FWFH]). Two-way ANOVA was performed to investigate the impact of WFH on depressive symptoms (Patient Health Questionnaire [PHQ-9] score), work productivity (Work Productivity and Activity Impairment scale [WPAI] scores), and QOL (EuroQol 5-Dimensions 5-Levels [EQ-5D-5L] score). The Tukey-Kramer test was used to assess differences between the stratified subgroups. Poisson and multiple regression analyses were also performed to assess the factors associated with these outcomes. Results: Other than PHQ-9 score between FWOS and hybrid work in workers with ADHD symptoms (p < 0.05), no significant differences were observed in outcomes among the working condition subgroups in both workers with and without ADHD symptoms. In workers with ADHD symptoms, hybrid work and FWFH were significantly associated with a lower PHQ-9 score (hybrid, p < 0.001; FWFH, p < 0.05) but neither were significantly associated with WPAI score nor EQ-5D-5L. Annual income and discretionary work were significantly associated with a lower PHQ-9 score and a higher EQ-5D-5L score in workers with ADHD symptoms. Job type (manufacture/construction) was significantly associated with a lower presenteeism score. Conclusion: WFH (hybrid and FWFH) may be associated with lower depressive symptoms compared with FWOS in undiagnosed workers with ADHD symptoms. The findings may be useful when considering suitable working environments for workers especially with ADHD symptoms.

Health-related quality of life in health states corresponding to different stages of perianal fistula associated with Crohn's disease: a quantitative evaluation of patients and non-patients in Japan.

Background: Perianal fistula (PF), a complication of Crohn's disease (CD), affects health-related quality of life (QOL). Objective: To elucidate QOL of health states corresponding to different stages of PF associated with CD in Japan. Method: This cross-sectional, observational, web-based questionnaire survey assessed eight different health states in patients with CD and PF and individuals without CD (non-patients) from the Medilead Healthcare Panel (MHP) and determined the utility values (QOL scores) in each health state by the time trade-off method. In patients, we determined also the utility value of the current health state associated with CD and the PF. The analysis excluded respondents with logical inconsistencies. Results: The analysis included 82 patients and 576 non-patients with the same sex and age distribution as the Japanese population. In both groups, mean utility values were higher in remission (patients, 0.78; non-patients, 0.51) than in non-remission states, with lowest values for poor prognosis after proctectomy (patients, 0.13; non-patients, -0.10) and highest values for the state with mild symptoms (patients, 0.60; non-patients, 0.30). In patients, the mean utility value of the current health state was 0.71. Conclusion: QOL decreases with increasing severity of PF and is lower for good prognosis after proctostomy than for remission.

Cost-effectiveness analyses of biologic and targeted synthetic disease-modifying anti-rheumatic diseases in patients with rheumatoid arthritis: Three approaches with a cohort simulation and real-world data.

OBJECTIVE: To assess the cost-effectiveness of biologic and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) in rheumatoid arthritis. METHODS: We conducted three analyses: a lifetime analysis with a cohort model (Study A) and two short-term analyses (Studies B and C). Study A evaluated the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained from costs of standard treatments. Study B evaluated yearly costs per person achieving American College of Rheumatology (ACR) response (ACR20, ACR50, and ACR70), and Study C evaluated costs per person achieving previously defined claims-based effectiveness (equivalent to 28-joint Disease Activity Score ≤ 3.2). The proportion of ACR responders to the drugs of interest were determined by mixed treatment comparisons. Studies B and C estimated costs using a claims database. RESULTS: In Study A, ICERs of all b/tsDMARDs were lower than 5.0 million Japanese yen (JPY) per QALY. In Study B, yearly costs per person with ACR50 response were lower for subcutaneous tocilizumab (TCZ-SC; 1.9 million JPY) and SC abatacept (2.3 million JPY). In Study C, costs per person were lower for TCZ-SC (1.3 million JPY) and intravenous TCZ (1.6 million JPY) and effectiveness rates were higher for intravenous TCZ (45.3%) and infliximab (43.0%). CONCLUSION: The b/tsDMARDs with lower prices showed higher cost-effectiveness.

Working Conditions, Work Productivity, Quality of Life, and Depressive Symptoms in Undiagnosed Adults with and without Attention-Deficit/Hyperactivity Disorder (ADHD) Symptoms During the COVID-19 Pandemic.

Purpose: This study aims to evaluate the impact of the COVID-19 pandemic on employment status, work productivity, quality of life (QOL), and depressive symptoms in undiagnosed adults with and without attention-deficit/hyperactivity disorder (ADHD) symptoms in Japan. Methods: An observational study used baseline data from a Japanese Medilead Healthcare Panel before the COVID-19 pandemic (October-December 2019). Eligible panel participants were then surveyed during the pandemic (March 2021). ADHD symptoms were screened using the Adult ADHD Self-Report Scale. Changes in QOL (EuroQol 5-Dimensions 5-Levels; EQ-5D-5L) and productivity impairment (Work Productivity and Activity Impairment scale; WPAI) from before to during the pandemic were analyzed in undiagnosed adults with and without ADHD symptoms. Unemployment rate and depressive symptoms (Patient Health Questionnaire; PHQ-9) during the pandemic were compared between groups. Results: Participants with (N=949) and without (N=942) ADHD symptoms completed the survey. The unemployment rate was not significantly different between participants with and without ADHD symptoms. Participants with ADHD symptoms were more likely to change jobs or employers during the pandemic. PHQ-9 scores in participants with ADHD symptoms were significantly higher than in those without ADHD symptoms (8.96 vs 3.57, respectively) during the pandemic. Before the pandemic, WPAI scores were significantly higher and EQ-5D-5L scores lower in participants with ADHD symptoms than in those without. Productivity improved and QOL was not altered during the pandemic in both groups, but productivity and QOL remained poorer among participants with ADHD symptoms than in those without. Conclusion: Productivity was improved among all participants during the COVID-19 pandemic, contrary to expectations. However, adults with ADHD symptoms consistently had lower productivity, poorer QOL, and more depressive symptoms than those without ADHD symptoms.

Trends in Corticosteroid Prescriptions for Ulcerative Colitis and Factors Associated with Long-Term Corticosteroid Use: Analysis Using Japanese Claims Data from 2006 to 2016.

BACKGROUND AND AIMS: Recent treatment guidelines for ulcerative colitis [UC] do not recommend long-term corticosteroid [CS] use. The present study aimed to capture the changes in CS use from 2006 to 2016 and to identify factors associated with long-term CS use after 2014, when the first two anti-tumour necrosis factor antibodies [infliximab and adalimumab] became available. METHODS: A retrospective study using the JMDC Claims Database included UC patients who initiated UC medications in any year from January 2006 to December 2016, or after January 2014, who were under continuous observation from 6 months before to 12 months after initiation. Patients with Crohn's disease before initiation and those prescribed <8 days of CSs were excluded. RESULTS: Among 7907 UC patients who initiated UC medications within the study period, 1555 were prescribed CSs. The proportion of patients using CSs in each year decreased from 2011 as use of thiopurines and biologics increased. The proportion of patients with a starting dose ≥30 mg/day of CSs and patients continuing CSs for <90 days increased from 2011, reaching 49.1% and 41.0%, respectively, in 2016. However, even in 2016, 34.3% continued to use CSs for ≥180 days. Among 1230 patients with CS use after January 2014, low initial CS dose [<10 mg/day] was most strongly associated with long-term CS use [≥180 days]. CONCLUSIONS: CS use became more appropriate as use of thiopurine and biologics increased, although there were still many cases of inappropriate use. Long-term CS use was most strongly associated with low initial doses of CSs.

Cellular response to substrate rigidity is governed by either stress or strain.

Cells sense the rigidity of their substrate; however, little is known about the physical variables that determine their response to this rigidity. Here, we report traction stress measurements carried out using fibroblasts on polyacrylamide gels with Young's moduli ranging from 6 to 110 kPa. We prepared the substrates by employing a modified method that involves N-acryloyl-6-aminocaproic acid (ACA). ACA allows for covalent binding between proteins and elastomers and thus introduces a more stable immobilization of collagen onto the substrate when compared to the conventional method of using sulfo-succinimidyl-6-(4-azido-2-nitrophenyl-amino) hexanoate (sulfo-SANPAH). Cells remove extracellular matrix proteins off the surface of gels coated using sulfo-SANPAH, which corresponds to lower values of traction stress and substrate deformation compared to gels coated using ACA. On soft ACA gels (Young's modulus <20 kPa), cell-exerted substrate deformation remains constant, independent of the substrate Young's modulus. In contrast, on stiff substrates (Young's modulus >20 kPa), traction stress plateaus at a limiting value and the substrate deformation decreases with increasing substrate rigidity. Sustained substrate strain on soft substrates and sustained traction stress on stiff substrates suggest these may be factors governing cellular responses to substrate rigidity.

Dual inhibition of Src and GSK3 maintains mouse embryonic stem cells, whose differentiation is mechanically regulated by Src signaling.

Recent studies reveal that the mechanical environment influences the behavior and function of various types of cells, including stem cells. However, signaling pathways involved in the mechanical regulation of stem cell properties remain largely unknown. Using polyacrylamide gels with varying Young's moduli as substrates, we demonstrate that mouse embryonic stem cells (mESCs) are induced to differentiate on substrates with defined elasticity, involving the Src-ShcA-MAP kinase pathway. While the dual inhibition of mitogen-activated protein (MAP) kinase and glycogen synthase kinase 3 (GSK3), termed "2i," was reported to sustain the pluripotency of mESCs, we find it to be substrate elasticity dependent. In contrast, Src inhibition in addition to 2i allows mESCs to retain their pluripotency independent of substrate elasticity. The alternative dual inhibition of Src and GSK3 ("alternative 2i") retains the pluripotency and self-renewal of mESCs in vitro and is instrumental in efficiently deriving mESCs from preimplantation mouse embryos. In addition, the transplantation of mESCs, maintained under the alternative 2i condition, to immunodeficient mice leads to the formation of teratomas that include differentiation into three germ layers. Furthermore, mESCs established with alternative 2i contributed to chimeric mice production and transmitted to the germline. These results reveal a role for Src-ShcA-MAP kinase signaling in the mechanical regulation of mESC properties and indicate that alternative 2i is a versatile tool for the maintenance of mESCs in serum-free conditions as well as for the derivation of mESCs.

Local mechanical stimulation of Mardin-Darby canine kidney cell sheets on temperature-responsive hydrogel.

Collective motion of cell sheets plays a role not only in development and repair, but also in devastating diseases such as cancer. However, unlike single-cell motility, collective motion of cell sheets involves complex cell-cell communication during migration; therefore, its mechanism is largely unknown. To elucidate propagation of signaling transduced by cell-cell interaction, we designed a hydrogel substrate that can cause local mechanical stretching of cell sheets. Poly (N-isopropyl acrylamide) (PNIPAAm) hydrogel is a temperature-responsive polymer gel whose volume changes isotropically in response to temperature changes below 37 °C. We designed a combined hydrogel substrate consisting of collagen-immobilized PNIPAAm as the local stimulation side and polyacrylamide (PAAm) as the non-stimulation side to assess propagation of mechanical transduction. Mardin-Darby canine kidney (MDCK) cells adhered to the collagen-immobilized PNIPAAm gel increased it area and were flattened as the gel swelled with temperature decrease. E-cadherin in these cells became undetectable in some domains, and actin stress fibers were more clearly observed at the cell base. In contrast, E-cadherin in cells adhered to the collagen-immobilized PAAm side was equally stained as that in cells adhered to the collagen-immobilized PAAm side even after temperature decrease. ERK1/2 MAPK activation of cells on the non-stimulated substrate occurred after partial stretching of the cell sheet suggesting the propagation of signaling. These results indicate that a change in the balance of mechanical tension induced by partial stretching of cell sheets leads to activation and propagation of the cell signaling.

Enantioselective total synthesis of (-)-candelalide A, a novel blocker of the voltage-gated potassium channel Kv1.3 for an immunosuppressive agent.

A convergent route to (-)-candelalide A involved the union of a trans-decalin portion (AB ring) and a gamma-pyrone moiety through the C16-C3' bond to assemble the whole carbon framework and subsequent formation of the dihydropyran ring (C ring) as the crucial steps. A strategic [2,3]-Wittig rearrangement was employed for establishing the stereogenic center at C9 and an exo-methylene function at C8 present in the decalin portion. [reaction: see text]

Spontaneous conception in a 50-year old woman after giving up in-vitro-fertilization (IVF) treatments: involvement of the psychological relief in successful pregnancy.

A healthy woman, married at age 45, hoped to have their child without delay. She and her husband subsequently decided to pursue in-vitro-fertilization and embryo transfer (IVF-ET). In the succeeding year, ET was performed twice from four oocyte retrieval attempts, which represented six ovarian stimulation cycles. Pregnancy was not achieved. Because of her poor responses to ovarian stimulation, inferior oocyte grading and prohibition of donor oocyte usage in Japan, the couple decided to discontinue further IVF treatment at age 48 years, 10 months. One and one-half years later, at age 50 years, 3 months she presented to our clinic eight weeks pregnant. At term she delivered vaginally a 2740 g healthy infant at 38 weeks gestation; Apgar scores were 9 and 10. During her pregnancy, she willingly participated in our questionnaire designed to provide information about her psychological well-being during the past three years. During the time spanning her treatment for infertility, anxiety, depression, irritability, fatigue and grief were revealed to coexist with her high hopes of having a child. After termination of infertility treatments these adverse psychological findings were markedly lessened and her vigour was restored. Stopping infertility treatment might be a viable alternative for achieving pregnancy in similarly psychologically-challenged infertile women.