Unresolved Palliative Care Needs of Elderly Non-Cancer Patients at Home: A Multicenter Prospective Study.

INTRODUCTION/OBJECTIVES: There is growing consensus on the benefits of initiating palliative care early in the disease trajectory; however, palliative care needs for non-cancer patients remain to be elucidated. We investigated the trajectory of unresolved palliative care needs of non-cancer patients at home and explored associated factors. METHODS: We conducted a multicenter prospective cohort study of elderly non-cancer patients at home in Japan between Jan 2020 and Dec 2020. Physicians assessed their palliative care needs using the Integrated Palliative Care Outcome Scale (IPOS). Unresolved palliative care needs were defined as IPOS symptoms above 2 (moderate). RESULTS: In total, 785 patients were enrolled. The most frequent unresolved palliative care needs at enrollment were poor mobility (n = 438, 55.8%), followed by weakness/lack of energy (n = 181, 23.1%) and poor appetite (n = 160, 20.4%). Multivariate logistic regression analysis revealed that female and musculoskeletal disease were significantly positively associated with pain at starting home visits (OR = 1.89, P = .015; OR = 2.69, P = .005). In addition, neurological diseases were significantly positively associated with constipation and poor mobility 3 months after starting home visits (OR = 3.75, P = .047; OR = 3.04, P = .009). CONCLUSIONS: The order of the prevalence of unresolved palliative care needs may remain relatively stable over time, even for those receiving home-based palliative care services. We identified several specific diseases and conditions that were significantly associated with unresolved palliative care needs.

Secondhand Smoke Exposure and Smoking Prevalence Among Adolescents.

Importance: Secondhand smoke is a substantial risk factor for youth health globally, including in Japan, where tobacco control policies should be reassessed. Objective: To assess trends in the prevalence of secondhand smoke exposure among Japanese adolescents from 2008 to 2017 and to examine the association between its frequency and smoking during the study period. Design, Setting, and Participants: This study comprised a nationally representative, self-administered, school-based, cross-sectional survey focusing on tobacco and alcohol use and related factors among students in grades 7 to 12 (ages 12-18 years) in Japan. This random sampling survey used single-stage cluster sampling. Using the national school directory, junior and senior high schools throughout Japan were randomly extracted from each regional block. All students enrolled in the sampled schools were included as participants, and school-based surveys were completed in 2008, 2012, and 2017. Data analysis was performed from January 1 to March 15, 2023. Main Outcomes and Measures: Prevalence of secondhand smoke exposure among adolescents in Japan from 2008 to 2017 and changes in the association between secondhand smoke exposure frequency and prevalence of smoking were examined using multiple logistic regression analysis. Results: Data were analyzed for 95 680 adolescents in 2008 (50.7% boys), 100 050 in 2012 (51.6% boys), and 64 152 in 2017 (53.9% boys). At baseline, 42.0%, 38.5%, and 34.6% of the participants were junior high school students in 2008, 2012, and 2017, respectively. Based on the 2008 surveys, 51.0% of adolescents in grades 7 to 12 were exposed to secondhand smoke in any place (≥1 day during the past 7 days), 37.2% were exposed at home, and 36.5% were exposed in public places. In 2017, 36.3% of participants were exposed to secondhand smoke in any place, 23.8% were exposed at home, and 27.0% were exposed in public places. An association between secondhand smoke exposure frequency and prevalence of smoking was observed consistently regardless of survey year, location, or pattern of exposure (adjusted odds ratios ranged from 2.29 [95% CI, 1.81-2.91] for 1-2 days at home to 11.15 [95% CI, 8.50-14.62] for 7 days in public places). Stratified analysis by higher education intention indicated that the prevalence of smoking and secondhand smoke exposure decreased but remained higher among adolescents who did not intend to pursue higher education. The association between secondhand smoke and smoking did not differ substantially between groups. Conclusions and Relevance: In this cross-sectional study, the prevalence of secondhand smoke exposure among adolescents in Japan decreased but remained at high levels overall. There may not be a hazard-free threshold for smoking. Enhancing comprehensive tobacco control strategies is Japan's first step toward achieving smoke-free environments to protect youths. Implementation and verification of the effectiveness of smoke-free legislation should be considered.

Is "pain before vomiting" useful?: Diagnostic performance of the classic patient history item in acute appendicitis.

BACKGROUND: In most surgical textbooks, it has been stated that pain almost always precedes vomiting in patients with appendicitis. However, the usefulness of this classic history item, "pain before vomiting", has been investigated in only one study nearly 50 years ago, in which the cause of abdominal pain could not be identified in more than 40% of patients. Accordingly, our objective was to evaluate the performance of pain before vomiting for the diagnosis of acute appendicitis in patients who presented with both acute abdominal pain and vomiting. METHODS: A retrospective chart review of adult outpatients with abdominal pain and vomiting at three acute care hospitals was performed. The reference standard for appendicitis was a CT scan evaluated by two radiologists. Diagnostic performance of pain before vomiting and the value it added to the Alvarado score were evaluated. RESULTS: Among 310 patients, 24 patients were diagnosed with appendicitis. Diagnostic performance of pain before vomiting was a sensitivity of 95.8% (95% confidence interval [CI] 79.8-99.3) and a specificity of 16.6% (95% CI 12.6-21.4). When combined with the Alvarado score, it ruled out appendicitis in an additional 12% (increased from 32% to 44%) of patients without any false negatives. CONCLUSIONS: "Pain before vomiting" is useful for ruling out appendicitis in patients with abdominal pain and vomiting.

Predictors of Malignancy in "Pure" Branch-Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas without Enhancing Mural Nodules on CT Imaging: A Nationwide Multicenter Study.

Background/Aims: Presence of enhanced mural nodules, which can be visualized using computed tomography (CT), is one of high-risk stigmata in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Conversely, the absence of enhanced mural nodules on preoperative imaging does not exclude malignant risk. The present study aimed to investigate other morphological features as predictors of malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Methods: This retrospective study included 180 patients with surgically confirmed "pure" BD-IPMNs of the pancreas and no enhanced mural nodules on preoperative CT. The study was conducted at 15 tertiary referral centers throughout South Korea. Univariate and multivariate analyses were used to identify significant predictors of malignancy. Results: BD-IPMNs with low-grade (n=84) or moderate-grade (n=76) dysplasia were classified as benign; those with high-grade dysplasia (n=8) or invasive carcinoma (n=12) were classified as malignant. The multivariate analysis revealed that cyst size ≥30 mm (odds ratio, 8.6; p=0.001) and main pancreatic duct diameter ≥5 mm (odds ratio, 4.1; p=0.01) were independent risk factors for malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Endoscopic ultrasound detected enhanced mural nodules (6/82) that had been missed on CT, and two IPMNs with enhanced mural nodules were malignant. Conclusions: In patients with "pure" BD-IPMNs who have no enhanced mural nodules on CT, cyst size ≥30 mm and main pancreatic duct diameter ≥5 mm may be associated with malignancy.

Predictors of malignancy in pure branch duct type intraductal papillary mucinous neoplasm of the pancreas: A nationwide multicenter study.

BACKGROUND/OBJECTIVES: Prediction of malignancy in patients with BD-IPMNs is critical for the management. The aim of this study was to elucidate predictors of malignancy in patients with 'pure' BD-IPMNs who had a main pancreatic duct (MPD) diameter of ≤5 mm according to the most recent international consensus criteria and in whom MPD involvement was excluded on postoperative histology. METHODS: We identified 177 patients with 'pure' BD-IPMNs based on preoperative imaging and postoperative histology from 15 tertiary referral centers in Korea. BD-IPMNs with low-grade (n = 72) and moderate-grade (n = 66) dysplasia were grouped as benign and BD-IPMNs with high-grade dysplasia (n = 10) and invasive carcinoma (n = 29) were grouped as malignancy. RESULTS: On univariate analysis, particular symptoms (jaundice and clinical pancreatitis), CT findings (cyst size > 3 cm, the presence of enhancing mural nodules) and EUS features (the presence of mural nodules, the mural nodule size > 5 mm) were significant risk factors predicting malignant BD-IPMNs. Multivariate analysis revealed that the cyst size > 3 cm (odds ratio = 9.9), the presence of enhancing mural nodules on CT (odds ratio = 19.3) and the mural nodule size > 5 mm on EUS (odds ratio = 14.9) were the independent risk factors for the presence of malignancy in BD-IPMNs (p < 0.001). CONCLUSIONS: The cyst size > 3 cm, the presence of enhancing mural nodules on CT, the mural nodule size > 5 mm on EUS are three independent predictors of malignancy in patients with 'pure' BD-IPMNs.

Three cases of Diphyllobothrium nihonkaiense infection in Korea.

Until 2012, a total of 48 cases of diphyllobothriasis had been reported in Korea, all of which were morphologically identified as Diphyllobothrium latum. However, some of these specimens were analyzed by nucleotide sequencing of the mitochondrial cox1 gene, which showed that all were D. nihonkaiense, not D. latum. After that, 3 further cases of diphyllobothriasis were confirmed as D. nihonkaiense. In the present study, 3 new cases of D. nihonkaiense were detected from 2011 through 2013. The hosts were infected through consumption of salmonid fishes, such as the trout or salmon, and 2 of them experienced severe diarrhea prior to proglottid passage. All of the tapeworms were confirmed to be D. nihonkaiense by genetic identification. This proved again that most diphyllobothriasis in Korea have been caused by D. nihonkaiense.

Cyclooxygenase-2 mediates mucin secretion from epithelial cells of lipopolysaccharide-treated canine gallbladder.

Biliary mucin was regarded as a major contributing factor in formation of pigment stones as well as cholesterol ones. The aim of this study was to elucidate the mechanism of biliary mucin secretion in canine gallbladder epithelial (CGBE) cells treated by lipopolysaccharides (LPS) with special reference to cyclooxygenase (COX) -2. Confluent CGBE cells were incubated with following compounds for 8, 12, and 24 hr: (1) serum-free medium, (2) serum-free medium containing LPS (100 microm/ml), (3) serum-free medium containing LPS (100 microm/ml) with NS-398 (10 microM), and (4) serum-free medium containing LPS (100 microm/ml) with indomethacin (10 microM). Mucin assay and western blots for COX-1 and COX-2 were performed. Production of PGE2, and cAMP was also measured. Mucin secretion increased with time. At 12 hr, mucin secretion increased to 200% of control (from 100 +/- 5 to 200 +/- 45%, P < 0.05). LPS treatment significantly stimulated the COX-2 expression (P < 0.05). The productions of PGE2 and cAMP were increased from 299 +/- 68 to 524 +/- 163 pg/mg (P < 0.05) and from 0.2 +/- 0.1 to 0.92 +/- 0.4 pmol/ml (P < 0.05), respectively. NS-398, which completely inhibited COX-2 expression, significantly suppressed the level of PGE2 and cAMP as well as mucin secretion (P < 0.05). Indomethacin, which partially inhibited COX-2 expression, suppressed the production of PGE2, but not cAMP and mucin secretion. In conclusion, our results suggested that the PGE2 induced by COX-2 might play a role in mucin secretion from the gallbladder epithelium through the increment of cAMP.

Cystic fibrosis transmembrane conductance regulators (CFTR) in biliary epithelium of patients with hepatolithiasis.

Cystic fibrosis transmembrane conductance regulator (CFTR) has been considered to be involved in the regulatory pathway of biliary mucin secretion. We investigated expression of CFTR protein and mRNA in 24 livers with hepatolithiasis, in 6 with cholangiocarcinoma, and in 12 histologically normal livers. According to the histologic features of chronic proliferative cholangitis, hepatolithiasis was subdivided into inflammatory cell infiltration predominant (N = 14) and fibrosis predominant (N = 10). The mean signal density of CFTR in overall hepatolithiasis and in histologically normal livers was 1.23 +/- 0.15 and 1.01 +/- 0.13, respectively (P > 0.05). The CFTR protein (1.60 +/- 0.18) and mRNA (1.09 +/- 0.15) in inflammatory cell infiltration predominant patients were significantly higher (CFTR protein, 1.01 +/- 0.13; mRNA, 0.75 +/- 0.11) than in control subjects (P < 0.05), whereas those in fibrosis-predominant patients (CFTR protein, 0.72 +/- 0.15; mRNA, 0.55 +/- 0.13) were less than in control subjects (P < 0.05). CFTR protein (1.27 +/- 0.17) in patients with cholangiocarcinoma was not different from that of control subjects (1.01 +/- 0.13). CFTR expression in hepatolithiasis patients was rather heterogeneous but was closely related to the histology of bile ducts.

Two juvenile hormone suppressible storage proteins may play different roles in Hyphantria cunea Drury.

We isolated and sequenced cDNA clones corresponding to two storage proteins (HcSP-1 and HcSP-2) from fall webworm, Hyphantria cunea. The cDNAs for HcSP-1 (2,337 bp) and HcSP-2 (2,572 bp) code for 753 and 747 residue proteins with predicted molecular masses of 88.3 and 88.5 kDa, respectively. The calculated isoelectric points are pI = 8.4 (HcSP-1) and 7.6 (HcSP-2). Multiple alignment analysis of the amino acid sequence revealed that HcSP-1 is most similar to SL-1 from S. litura (73.8% identity) and other methionine-rich hexamers, whereas HcSP-2 is most similar to the SL-2 alpha subunit from S. litura (74.8% identity) and other moderately methionine-rich hexamers. The two storage proteins from H. cunea shared only 38.4% identity with one another. According to both phylogenetic analyses and the criteria of amino acid composition, HcSP-1 belongs to the subfamily of Met-rich storage proteins (6% methionine, 10% aromatic amino acid), and HcSP-2 belongs to the subfamily of moderately methionine-rich storage proteins (3.2% methionine, 12.9% aromatic amino acid). Topical application of the JH analog, methoprene, after head ligation of larvae, suppressed transcription of the SP genes, indicating hormonal effects at the transcriptional level. The HcSP-1 transcript was detected by Northern blot analysis in Malpighian tubule, testis, and ovary, in addition to fat body where it was most abundant. The HcSP-2 transcript was detected only in fat body and Malpighian tubule. The accumulation of HcSP-1 in ovary and HcSP-2 in Malpighian tubule might be related to differential functions in both organs.

Normal structure, variations, and anomalies of the pancreaticobiliary ducts of Koreans: a nationwide cooperative prospective study.

BACKGROUND: This study evaluated the normal pancreaticobiliary ducts of Koreans and assessed the frequency and pattern of variations and anomalies of these structures. METHODS: A prospective, nationwide multicenter study was performed in which 10 university hospitals in Korea participated from March 1997 to June 1999. A total 10,243 patients undergoing ERCP were enrolled. RESULTS: The mean (SD) maximal and midportion diameters in millimeters of the common hepatic duct were, respectively, 6.1 (1.8) and 5.3 (1.6). The mean maximal and midportion diameters (mm) of the common bile duct were, respectively, 6.4 (1.8) and 5.5 (1.7). The mean maximal and midportion diameters (mm) of the main pancreatic duct in the head, body and tail were, respectively, 3.2 (1.1), 2.7 (1.0), and 2.5 (2.3); and, respectively, 2.2 (0.9), 1.6 (0.7) and 1.4 (0.6). Pancreaticobiliary duct diameters for patients above the age of 40 were greater than those of patients less than 40 years of age (p < 0.05). The frequency of choledochal cyst and anomalous union of the pancreaticobiliary ducts were, respectively, 0.32% and 4.1%. Pancreas divisum and annular pancreas were found, respectively, in 0.49% and 0.05%. CONCLUSIONS: A knowledge of normal pancreaticobiliary ductal structures as well as the frequency and pattern of variations including anomalies is essential for the diagnosis and treatment of pancreaticobiliary disorders.