Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Optimal placement of self-fixating mesh in the rectus abdominis muscle for ventral hernia repair when using the enhanced-view totally extraperitoneal Rives-Stoppa technique.

INTRODUCTION: Laparoscopic retro-muscular Rives-Stoppa (RS) ventral hernia repair using the enhanced-view totally extraperitoneal (eTEP) technique (eTEP-RS) is becoming common. Although self-fixating mesh is useful with good fixation, some surgeons think the fixating surface must be oriented towards the rectus abdominis muscle for safety reasons in eTEP-RS. Attaching the self-fixating mesh to the rectus abdominis, the ceiling of the operative field, is challenging and time-consuming. MATERIAL AND SURGICAL TECHNIQUE: First, the self-fixating mesh is folded in half with the fixation surface facing outwards. Second, we create a partition sheet and insert the sheet between the two arms of the folded mesh. The folded mesh is then inserted intracorporeally. We can unfold the mesh easily from one-quarter width to half width on the rectus abdominis muscle because of the insertion of the partition sheet. Finally, the mesh is unfolded to full width, and the mesh placement is completed. DISCUSSION: The eTEP-RS is still a new procedure and has not yet been standardized. However, our technique will increase the use of self-fixating mesh and improve the outcomes of eTEP-RS.

[A Case of Pyloric Stenosis Due to Gastric Metastasis of Breast Cancer].

We report a case of left advanced breast cancer(T4N1M0, Stage ⅢA)in a 67-year-old woman. In August 2010, her breast cancer(triple-negative invasive ductal carcinoma)was resected(mastectomy plus axillary lymph node dissection) with adjuvant chemotherapy(TC)and irradiation to her chest wall. In July 2018, she experienced recurrent vomiting. Gastrointestinal endoscopy(GS)revealed type Ⅳ advanced gastric cancer-like appearance with pyloric stenosis. Pathological findings confirmed hormone-positive gastric metastasis of breast cancer. Systemic chemo-endocrine therapy(EC and anastrozole) was performed, following which her symptoms improved. In May 2019, recurrent vomiting appeared again. Thereafter, systemic chemo-endocrine therapy(paclitaxel plus bevacizumab and fulvestrant)was initiated, and her symptoms showed improvement. In November 2020, she showed obstructive jaundice due to malignant biliary stenosis. She was treated using endoscopic biliary stenting, but died 2 months later. Gastric metastasis is reported rarely in 4% of all breast cancers, and GS should be recommended in cases of recurrent abdominal complaints.

Emergence of artistic talent in progressive nonfluent aphasia: a case report.

Some patients with frontotemporal lobar degeneration have developed artistic skills after the onset mainly in painting and music. Most of these cases have semantic dementia (SD), one of the frontotemporal lobar degeneration subtypes. In previously reported cases, the paintings made by patients with SD were usually hyper realistic, without a significant symbolic or abstract component. Here, we report on a patient with progressive nonfluent aphasia (PNFA), another frontotemporal lobar degeneration subtype, who started making creative bamboo crafts after PNFA onset. His techniques were completely his original; he devised the shapes of the crafts and made them without samples. His work did not become an obsessive preoccupation. The artistic style expressed by patients with PNFA differs from that expressed by patients with SD. Therefore, the underlying mechanisms for the emergence of artistic talent might differ between SD and PNFA.

Are saving appearance responses typical communication patterns in Alzheimer's disease?

INTRODUCTION: To keep up appearances, people with dementia sometimes pretend to know the correct answer, as seen during administration of neuropsychological tests such as the Mini-Mental State Examination (MMSE). These saving appearance responses (SARs) of people with dementia often lead to caregivers and/or medical staff underestimating the severity of dementia and impede proper early initiation of treatment. However, most descriptions of SARs are based on empirical knowledge of clinicians. In this study, we investigated whether SARs are typical communication patterns in people with Alzheimer's disease (AD), compared with mild cognitive impairment (MCI) or dementia with Lewy bodies (DLB). METHODS: The participants were 107 outpatients with AD, 16 with mixed AD with cerebrovascular dementia, 55 with MCI, and 30 with DLB. We assessed the occurrence of SARs during the MMSE. The relationships between the SARs and AD were examined by the χ2 test and logistic regression analysis. RESULTS: People with AD who showed SARs were 57.9%, whereas those with MCI were 18.2% and DLB were 20.0% (P with Bonferroni correction < 0.05). Although there were significant differences in some variables in each group of diagnosis, logistic regression analysis showed that people with AD were more likely to show SARs than those with MCI (Odds ratio = 3.48, 95% Confidential Interval = 1.18-10.28) and DLB (Odds ratio = 4.24, 95% Confidential Interval = 1.50-12.01), even after controlling for sex, estimated disease duration, MMSE, and frontal assessment battery scores. CONCLUSION: The occurrence of SARs could be found most frequently in people with AD. Clinicians should develop a respectful attitude toward dementia patients with SARs because SARs imply conflicted feelings about questions that patients cannot answer correctly.

Why do people with dementia pretend to know the correct answer? A qualitative study on the behaviour of toritsukuroi to keep up appearances.

BACKGROUND: Toritsukuroi is a particular type of behaviour intended to save face or preserve appearances. Clinicians often observe toritsukuroi in people with dementia, but current knowledge about this behaviour is based on clinicians' empirical knowledge rather than on observational studies. This study was designed to clarify which behaviours are related to toritsukuroi based on neuropsychological examinations. METHODS: The subjects were 91 outpatients with dementia. Verbal responses, with the exceptions of 'I don't know' and erroneous answers, were recorded by certificated clinical psychologists and analyzed by qualitative study procedures. A qualitative study was separately conducted by two researchers to identify themes and types of reactions. The themes found through content analysis were organized and labelled by a senior psychiatrist. RESULTS: Among the patients, 41.8% verbally responded in way to 'keep up appearances'. Six distinct thematic categories were identified through conventional content analysis: (i) refuting sudden questions; (ii) disclosing trait; (iii) disclosing experience; (iv) demonstrating slight hesitation; (v) appealing to indifference; and (vi) other. CONCLUSIONS: All the responses that we defined as being toritsukuroi reflect a denial of acquired cognitive impairment. Further study is needed to clarify the association between toritsukuroi and either cognitive function or disease specificity.

Relationship between Dementia Severity and Behavioral and Psychological Symptoms of Dementia in Dementia with Lewy Bodies and Alzheimer's Disease Patients.

BACKGROUND/AIMS: Behavioral and psychological symptoms of dementia (BPSD) are common in the clinical manifestation of dementia. Although most patients with dementia exhibit some BPSD during the course of the illness, the association of BPSD with the stage of dementia remains unclear. It was the aim of this study to evaluate the impact of severity of dementia on the expression of BPSD in patients with dementia with Lewy bodies (DLB) and Alzheimer's disease (AD). METHODS: Ninety-seven patients with DLB and 393 patients with AD were recruited from 8 dementia clinics across Japan. BPSD were assessed by the Neuropsychiatric Inventory (NPI). A relationship between BPSD and dementia stage classified by the Clinical Dementia Rating (CDR) in each type of dementia was assessed. RESULTS: No significant difference was seen in NPI total score across CDR staging in the DLB group. On the other hand, the NPI total score significantly increased with dementia stage in the AD group. CONCLUSION: The relationship of dementia stage with the expression of BPSD was different according to the type of dementia. BPSD and dementia stage were correlated in AD subjects, in whom psychiatric symptoms increase as the disease progresses, but not in DLB subjects.

Relationship between dementia severity and behavioural and psychological symptoms in early-onset Alzheimer's disease.

BACKGROUND: The features of behavioural and psychological symptoms of dementia (BPSD) are influenced by dementia stage. In early-onset Alzheimer's disease (EOAD), the association between BPSD and dementia stage remains unclear because of the difficulty of recruiting subjects with a wide range of disease severity. We used a combination of community-based and hospital-based approaches to investigate the relationship between dementia severity and BPSD in EOAD patients. METHODS: Sixty-three consecutive EOAD outpatients and 29 EOAD patients from a community-based survey were divided into three dementia severity groups according to the Clinical Dementia Rating scale (CDR): mild (CDR 0.5-1, n = 55), moderate (CDR 2, n = 17), and severe (CDR 3, n = 20). BPSD were rated using the Neuropsychiatric Inventory. RESULTS: Scores of the Neuropsychiatric Inventory subscales agitation, euphoria, apathy, disinhibition, irritability, and aberrant motor behaviour increased significantly with increased dementia severity. Hallucinations were greater in the moderate group than in the mild group. For delusions, depression, and anxiety, no significant differences were observed among the three severity groups. CONCLUSIONS: The pattern of apathy, agitation, disinhibition, irritability, and aberrant motor behaviour worsening with severity progression in EOAD is similar to the pattern in late-onset Alzheimer's disease. In contrast, hallucinations, depression, and anxiety showed different patterns in EOAD.

Patient-related factors associated with depressive state in caregivers of patients with dementia at home.

OBJECTVES: To identify patient-related factors associated with depressive state in caregivers of patients with dementia, we investigated the caregivers' and patients' characteristics in relation to the depressive state in their caregivers. DESIGN: Prospective hospital-based cohort study. SETTING: Two memory clinics in Japan. PARTICIPANTS: Outpatients with dementia (n = 135) and their caregivers at home. MEASUREMENTS: The outpatients and their caregivers were divided into 2 groups according to the Center for Epidemiologic Studies Depression Scale for caregivers. To identify the patient-related factors that cause depressive state in caregivers, Mini-Mental State Examination (MMSE), the Physical Self-Maintenance Scale for fundamental activities of daily living (ADL), and the instrumental ADL scale (IADL) scores for instrumental ADL and the neuropsychiatric inventory (NPI) subscale score for behavioral and psychological symptoms of dementia were compared between the 2 groups. We used logistic regression to determine the independent predictors of caregiver depressive state. RESULTS: There was no significant difference in MMSE score between the 2 groups. Logistic regression analysis revealed that the depressive state in caregivers was related with IADL score and delusion in NPI subscale of patients. CONCLUSIONS: Depressive state in caregivers was independent of the decline in cognitive function in patients with dementia but was associated with decline in instrumental ADL and severity of delusion.

Efficacy of increasing donepezil in mild to moderate Alzheimer's disease patients who show a diminished response to 5 mg donepezil: a preliminary study.

BACKGROUND: With the recent approval of several new drugs, pharmacological management of Alzheimer's disease has become more complicated in Japan. The efficacy and safety of increasing the dose of donepezil to 10 mg daily were assessed in an open-label study of patients with mild to moderate Alzheimer's disease who were showing a diminished response to 5 mg daily. METHODS: The subjects included 27 patients with mild to moderate probable Alzheimer's disease whose primary caregivers had confirmed progression of symptoms during treatment with donepezil 5 mg daily. The dose of donepezil was increased to 10 mg daily, and the Alzheimer's disease assessment scale-cognitive subscale (Japanese version), Neuropsychiatric Inventory, and Zarit caregiver burden interview scores were compared before and after dose escalation. Adverse events were also investigated. RESULTS: Efficacy was evaluated in 24 patients; three dropped out because of adverse reactions. The Alzheimer's disease assessment scale score showed significant improvement after dose escalation of donepezil (P = 0.006). The total score of the Neuropsychiatric Inventory and the Zarit score showed no significant changes. However, the anxiety score of the Neuropsychiatric Inventory showed a significant increase (P = 0.028). Safety assessment revealed that the dropout rate was 11.1% and adverse reactions occurred in 40.7%. Nausea (29.6%) and loss of appetite (22.2%) were common adverse reactions. CONCLUSIONS: Because cognitive function showed improvement after increasing the dose of donepezil, the dosage of this drug should probably be adjusted based on the overall severity of Alzheimer's disease as well as the progression of cognitive dysfunction.

The usefulness of monitoring sleep talking for the diagnosis of Dementia with Lewy bodies.

BACKGROUND: Dementia with Lewy bodies (DLB) is the second most common type of neurodegenerative dementia. It is frequently difficult to differentiate DLB from Alzheimer's disease (AD) and other types of dementia. This study examined the usefulness of monitoring sleep talking for the diagnosis of DLB. METHODS: A total of 317 patients with dementia were selected from a consecutive series at the Dementia Clinic of Kumamoto University Hospital. Diagnostic categories consisted of probable DLB (n = 55), probable AD (n = 191), frontotemporal lobar degeneration (FTLD) (n = 16), vascular dementia (VaD) (n = 18), and other/unspecified dementia (n = 37). We evaluated sleep talking in all dementia patients and normal elderly subjects (n = 32) using an originally designed sleep talking questionnaire. RESULTS: Sleep talking occurred most frequently in the DLB group (61.8%), followed by the VaD group (33.3%), other/unspecified dementia group (27.0%), AD group (18.8%), FTLD group (12.5%), and normal elderly subjects group (6.3%). The prevalence of sleep talking in the DLB group was significantly higher than in other groups, except in the VaD group. The sleep talking yielded high specificity (81.2%) and some sensitivity (61.8%) for the differential diagnosis of DLB from AD. Furthermore, loud sleep talking may improve the specificity (96.9%). For the differentiation of DLB from all other dementia types, the specificity of sleep talking and loud sleep talking was also high (79.4% and 95.8% respectively). CONCLUSIONS: Assessing sleep talking, especially the volume of sleep talking, may be useful in the clinical discrimination of DLB from not only AD but also from all other types of dementia.

Association of cerebral small vessel disease with delusions in patients with Alzheimer's disease.

BACKGROUND: Cerebral small vessel disease (SVD) is frequently observed in patients with Alzheimer's disease (AD). However, the association between SVD and clinical symptoms exhibited by patients with AD remains unclear. This study examined the association of SVD as observed on magnetic resonance imaging (MRI) with behavioural and psychological symptoms of dementia and cognitive function of patients with probable AD. METHODS: A total of 163 consecutive patients (55 men, 108 women) with probable AD were included in this cross-sectional study of a prospective cohort. Patients were divided into two groups based on the presence or absence of cerebral SVD [white matter hyperintensities (WMH) grade 0/1 (Fazekas scale) and no lacunes: SVD absent, WMH grade 2/3 (Fazekas scale) or the number of lacunes ≥1: SVD present]. Cognitive functions were assessed using the Mini mental state examination, word recall and recognition subtests in the Alzheimer's Disease Assessment Scale-Cognitive Subscale, as well as the letter fluency task and the category fluency task. Psychiatric symptoms were rated according to Neuropsychiatric Inventory. RESULTS: Patients with probable AD with cerebral SVD had significantly more delusions and depression than those without SVD. No significant differences were observed in other neuropsychiatric symptoms, MMSE or word recall and recognition tests between both groups. CONCLUSIONS: Our results suggest that cerebral SVD observed on MRI of patients with AD is associated with delusions and depression.

A comparison of family care infrastructure for demented elderly in inner cities and regional areas in Japan.

BACKGROUND: Family members' observations of daily life are important for the diagnosis and treatment of dementia. However, elderly people are increasingly living alone, and family structures tend to differ between inner-city areas and regional areas. We aimed to compare the family caregiving infrastructure of demented elderly visiting a memory clinic. METHODS: Subjects were consecutive outpatients with dementia at the memory clinic at a university hospital in two different areas. We compared subjects' demographic data, residency status, housemates and companion status at the time of their initial visit. RESULTS: Patients in the inner-city area (n= 99) had more education and higher Mini-Mental State Examination scores than those in the regional area (n= 172). In both areas, the highest proportion of patients lived with their spouse. In the inner city, patients' housemates were either their spouse (34%) or their child (13%); 22% lived alone. In regional areas, patients lived with their spouse only (39%) or in their child's household (23%); 14% lived alone. At their initial consultation, inner-city patients were accompanied by a family member other than their spouse (49%), a spouse (27%), or they were alone (7%). In the regional area, patients' companions were their spouse (35%) or their spouse and other family members (18%); patients rarely arrived alone. Regression analysis showed that education, diagnosis, housemate state (child only), and companion state (alone) significantly influenced the living area. CONCLUSION: Our results suggest family caregiving infrastructure of demented elderly differ between the two areas. This may reflect changes in social structure and increased awareness regarding dementia in inner-city areas.

Neuropsychiatric symptoms of progressive supranuclear palsy in a dementia clinic.

BACKGROUND: Progressive supranuclear palsy (PSP) is a neurodegenerative disease characterized by supranuclear gaze palsy, postural instability, akinesia and other parkinsonism. Recently, the relationship between PSP and frontotemporal dementia (FTD) has been recognized, which includes clinical, pathological, biochemical and genetic features. However, there have been few studies that directly compared neuropsychiatric symptoms between PSP and FTD. The aim of the present study was to investigate comprehensive psychiatric and behavioural symptoms in PSP and compared them with those in FTD. METHODS: Patients with PSP (n = 10) and FTD (n = 13) were selected on the basis of inclusion/exclusion criteria from a consecutive series in the dementia clinic of Kumamoto University Hospital. We assessed their comprehensive neuropsychiatric features by using the Neuropsychiatric Inventory (NPI), the Stereotypy Rating Inventory (SRI) and a specific antisocial behaviour checklist. RESULTS: There were no significant differences in the total NPI and NPI subscale scores between the two groups. Both groups showed quite a similar pattern in the features of neuropsychiatric symptoms: apathy showed the highest score, followed by aberrant motor behaviour and disinhibition. The PSP group was significantly lower in the total SRI and eating and cooking behaviour scores than those in the FTD group. The prevalence of antisocial behaviours in PSP (50%) was equal to those in the FTD group (46%). CONCLUSIONS: In a dementia clinic, the neuropsychiatric profile in patients with PSP closely resembled those in the FTD group. The present results suggest that PSP should be considered as not only a movement disorder, but also a disorder with a wide range of neuropsychiatric symptoms.

Impact of donepezil hydrochloride on the care burden of family caregivers of patients with Alzheimer's disease.

BACKGROUND: To evaluate the impact of donepezil hydrochloride on the care burden on family members of patients with Alzheimer's disease (AD). At present, donepezil is the only drug approved for the treatment of AD in Japan. Although the care burden on primary caregivers of AD patients comprises both physical and psychological burdens and donepezil is recognized to improve cognitive dysfunction and associated symptoms, there are few data on the effects of the drug on the care burden. METHODS: Of the uninstitutionalized AD patients who visited a dementia clinic between June 2008 and May 2009 with their primary family caregivers, 416 subjects who satisfied the enrollment criteria were registered for the study. All participants provided informed consent. Assessment included changes in scores on the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI) and the Mini-Mental State Examination (MMSE), as well as the presence of behavioral and psychological symptoms of dementia (BPSD). Caregivers answered the questionnaires at baseline and after 12 weeks treatment with donepezil (starting dose 3 mg, p.o., once daily, followed by 5 mg after 1 or 2 weeks). RESULTS: There were significant changes in mean scores on the J-ZBI (-1.9 +/- 9.5; P < 0.01) and MMSE (+0.9 +/- 2.9; P < 0.01) from baseline to Week 12, without significant correlation between these two scores. In patients with BPSD, there was a significant decrease in J-ZBI scores over the 12 weeks (P = 0.013); in contrast, in patients without BPSD, the decrease in the J-ZBI score did not reach statistical significance (P = 0.418). CONCLUSIONS: The results indicate that donepezil improves cognitive function and some of the BPSD. As a possible consequence of improvements in BPSD, donepezil may also reduce caregivers' burden.