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Kotomi Sakai,1,2 Enri Nakayama,3 Nicole Rogus-Pulia,4,5 Takahiro Takehisa,6 Yozo Takehisa,6 Kevin Y Urayama,2,7 Osamu Takahashi2 1Department of Rehabilitation Medicine, Setagaya Memorial Hospital, Tokyo, Japan; 2Graduate School of Public Health, St. Luke’s International University, Tokyo, Japan; 3Department of Dysphagia Rehabilitation, Nihon University School of Dentistry, Tokyo, Japan; 4Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA; 5Geriatric Research Education and Clinical Center (GRECC), William S. Middleton Memorial Veterans Hospital, Madison, WI, USA; 6Heisei Medical Welfare Group, Tokyo, Japan; 7Department of Social Medicine, National Center for Child Health and Development, Tokyo, JapanCorrespondence: Kotomi SakaiDepartment of Rehabilitation Medicine, Setagaya Memorial Hospital, 2-30-10 Noge, Setagaya, Tokyo 158-0092, JapanTel +81-3-3703-5100Email koto.sakai1227@gmail.comPurpose: The objectives of this study were two-fold: 1) to investigate differences in activity duration and amplitude of the submental muscles during swallowing measured with surface electromyography (sEMG) in older patients with sarcopenic dysphagia compared to those without dysphagia and 2) to examine the diagnostic accuracy of submental sEMG signals for sarcopenic dysphagia.Patients and Methods: Patients (n = 60) aged ≥ 65 years participated in this cross-sectional study. The submental muscle activity duration parameters were the duration from the onset of swallowing to the maximum amplitude (duration A), duration from the maximum amplitude to the end of the swallowing activity (duration B), and total duration. The amplitude parameters were mean and maximum amplitude. Maximum lingual pressures were also measured for comparison with sEMG parameters.Results: Duration A was not significantly different between the groups (p = 0.15), but duration B (p < 0.001) and total duration (p < 0.001) were significantly different between the non-dysphagic and sarcopenic dysphagic groups. The mean (p = 0.014) and maximum (p < 0.001) amplitudes were significantly different between the groups. The area under the receiver operating characteristic curve (AUC) was 0.94 (95% confidence interval (CI) 0.87– 0.98) for duration B, 0.95 (95% CI 0.89– 0.99) for total duration, 0.76 (95% CI 0.63– 0.87) for maximum amplitude, and 0.61 (95% CI 0.47– 0.75) for mean amplitude. The AUC of the total duration was significantly greater than that of lingual pressure (p = 0.02).Conclusion: Patients with sarcopenic dysphagia had longer submental muscle activity duration and higher amplitude during swallowing as assessed using sEMG. The findings of this study can be useful in elucidating the underlying pathophysiology of sarcopenic dysphagia and in diagnosing sarcopenic dysphagia.Keywords: sarcopenia, deglutition disorders, electromyography, pharyngeal muscles

Eiji Hiraoka,1 Junya Arai,1 Shunsuke Kojima,1 Yasuhiro Norisue,2 Toshihiko Suzuki,3 Yosuke Homma,4 Osamu Takahashi,5 Kotaro Obunai,6 Hiroyuki Watanabe6 1Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan; 2Department of Critical Care and Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan; 3Department of Nephrology, Endocrinology, and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan; 4Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, Japan; 5Department of Internal Medicine, St Luke’s International Hospital, Chuo-ku, Tokyo 104-8560, Japan; 6Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu-city, Chiba 279-0001, JapanCorrespondence: Eiji HiraokaDepartment of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32, Todaijima, Urayasu-city, Chiba 279-0001, JapanTel +81-47-351-3101Fax +81-47-3512-6237Email eijih@jadecom.jpPurpose: An early do-not-resuscitate (DNR) order is classified as such when it occurs within 24 hours of admission. Early DNR has been previously associated with in-hospital mortality among acute heart failure (AHF) patients and one-year mortality among patients discharged from ICU. Here, we investigate whether early DNR is associated with long-term mortality in AHF Japanese patients, by performing a retrospective cohort study.Patients and Methods: We retrospectively investigated all patients with AHF, admitted to our hospital between April 2013 and March 2015, and survived to discharge. We obtained data on demographics, comorbidities, laboratory and echocardiography results, social background, DNR status, and outcomes (one-year death). The association of early DNR with one-year death was analyzed by multivariate logistic regression analysis.Results: Among 370 survive to discharge patients, 48 (12%) were lost to follow up. We analyzed 322 patients. The median age was 74 years, and 80 (25%) had an early DNR order. Patients with a DNR order were older and displayed more activities of daily living (ADL)-dependence. Early DNR was associated with higher one-year mortality.Conclusion: Early DNR was associated with one-year mortality among AHF patients. Further studies are necessary to investigate unmeasured factors associated with a worse prognosis related to early DNR among AHF patients.Keywords: acute heart failure, early DNR, prognosis, end of life, advance care planning

Shunsuke Kojima,1 Eiji Hiraoka,1 Junya Arai,1 Yosuke Homma,2 Yasuhiro Norisue,3 Osamu Takahashi,4 Taihei Soma,1 Toshihiko Suzuki,5 Masahiko Noguchi,6 Kentaro Shibayama,6 Kotaro Obunai,6 Hiroyuki Watanabe6 1Department of Internal Medicine, 2Department of Emergency Medicine, 3Department of Critical Care and Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu-city, Chiba 279-0001, Japan; 4Department of Internal Medicine, St Luke’s International Hospital, Chuo-ku, Tokyo 104-8560, Japan; 5Department of Nephrology, Endocrinology, and Diabetes, 6Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu-city, Chiba 279-0001, Japan Background: A do-not-resuscitate (DNR) order is reportedly associated with a decrease in performance measures, but it should not be applied to noncardiopulmonary resuscitation procedures. Good performance measures are associated with improvement in heart failure outcomes.Aim: To analyze the influence of DNR order on performance measures of heart failure at our hospital, where lectures on DNR order are held every 3 months.Design: Retrospective cohort study.Methods: The medical report of patients with acute heart failure who were admitted between April 2013 and March 2015 were retrospectively analyzed. We collected demographic data, information on the presence or absence of DNR order within 24 hours of admission, and inhospital mortality. Performance measures of heart failure, including assessment of cardiac function and discharge prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and beta-blocker for left ventricular systolic dysfunction and anticoagulant for atrial fibrillation, were collected and compared between groups with and without DNR orders.Results: In 394 total patients and 183 patients with left ventricular systolic dysfunction, 114 (30%) and 44 (24%) patients, respectively, had a DNR order. Patients with a DNR order had higher inhospital mortality. There were no significant differences between the two groups in terms of the four quality measures (left ventricular function assessment, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, and anticoagulant).Conclusion: DNR orders did not affect performance measures, but they were associated with higher inhospital mortality among acute heart failure patients. Keywords: do-not-resuscitate discussion, DNR order, acute heart failure, quality-of-care performance

Kazuyoshi Kurashima,1 Yotaro Takaku,1 Chie Ohta,1 Noboru Takayanagi,1 Tsutomu Yanagisawa,1 Tetsu Kanauchi,2 Osamu Takahashi3 1Department of Respiratory Medicine, 2Department of Radiology, Saitama Cardiovascular and Respiratory Center, Kumagaya, 3Center for Clinical Epidemiology, St Luke’s International Hospital, Tokyo, Japan Background: Emphysema is a distinct feature for classifying COPD, and smoking history (≥10 pack-years) is one of several newly proposed criteria for asthma–COPD overlap (ACO). We studied whether or not a smoking history (≥10 pack-years) and emphysema are useful markers for classifying ACO and differentiating it from asthma with chronic airflow obstruction (CAO). Methods: We retrospectively studied the mortalities and frequencies of exacerbation in 256 consecutive patients with ACO (161 with emphysema and 95 without emphysema) who had ≥10 pack-years smoking history, 64 asthma patients with CAO but less of a smoking history (

Akinori Sasaki,1 Eiji Hiraoka,1 Yosuke Homma,2 Osamu Takahashi,3 Yasuhiro Norisue,4 Koji Kawai,5 Shigeki Fujitani4 1Department of Internal Medicine, 2Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba, 3Department of Internal Medicine, St. Luke’s International Hospital, Chuo-ku, Tokyo, 4Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba, 5Department of Gastroenterology, Ito Municipal Hospital, Ito City, Shizuoka, Japan Background: Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases. Methods: We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis. Results: Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P

Eiji Hiraoka,1 Yosuke Homma,2 Yasuhiro Norisue,3 Takaki Naito,1 Yuko Kataoka,1 Osamu Hamada,1 Yo Den,1 Osamu Takahashi,4 Shigeki Fujitani3 1Department of Internal Medicine, 2Department of Emergency Medicine, 3Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan; 4Department of Internal Medicine, St Luke’s International Hospital, Tokyo, Japan Background: Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures.Methods: A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated.Results: We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%).Conclusion: DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm. Keywords: code status, do-not-resuscitate order (DNR)

Objective: Health locus of control (HLC) is associated with health behaviours. We aimed to investigate the difference of HLC to understand the potential gap in health beliefs between physicians and the general public. Design and setting: Physicians and the general public were surveyed in Japan using a cross-sectional survey. Data on the Japanese version of the HLC scale (HLCS-J) from 2194 members of the general public and 895 physicians were available. Method: Multi-group structural equation modelling analysis was used for examining differential item functioning (DIF) in the HLCS-J between the groups. Results: Uniform DIF was identified for the dimensions of internal, professional control and control by spiritual powers. Mean score for chance control (17.2) among physicians was greater than that (14.9) among the general public (adjusted p less than 0.001), while mean score for family control (21.7) among physicians was lower than that (22.1) among the general public (adjusted p less than 0.001). Conclusion: Physicians are more likely to have a higher chance control but lower family control than the general public. Further studies are needed to evaluate the relationships between individual physicians' HLC and their health behaviours. (Contains 4 tables.)

An approach, computational shape analysis (CSA), is presented here which utilizes a Fourier-wavelet representation to numerically describe shape features of biological forms. Two elements are involved: 1) elliptical Fourier functions (EFFs), to provide estimates of global aspects, and 2t continuous wavelet transforms (CWTs) to generate an objective estimate of localized features. EFFs are computed, using a set of pseudohomologous points, to create a precise analog of the boundary. This computed contour is then normalized by scaling and rotated in two-dimensional space to insure a representation that is invariant with respect to starting point, size, and orientation. The predicted point coordinates derived from the EFFs are submitted to CWT for further processing. Wavelet coefficients are then computed to identify localized features, localization being a subjective process with EFFs. The advantage of wavelets is that they eliminate the inevitable subjectivity inherent in the choice of measurements. To test the usefulness of CSA, a sample of cranial base (CB) lateral radio graphic outlines was available. Five archaeological periods, Yayoi, Kofun, Kamakura, Edo, and Modern, were utilized (n = 297). Statistically significant differences in sex and archaeological age were found. Although archaeological age differences were present, they were small and random in character, suggesting stability in the CB structures. In contrast, sexually dimorphic differences were present in every group from the Yayoi to the Modern period. This presence of sexually dimorphic differences in shape was consistent with earlier studies of M. nemestrina, G. gorilla, and P. troglodytes. Consequently, it is suggested that the pattern of sexual dimorphism documented in the Japanese CB is a primate pattern with an ancient evolutionary history. The results demonstrate, both visually and numerically, that CSA is a powerful approach for describing both global and localized features of craniofacial structures such as the CB. KEY WORDS elliptical Fourier functions; continuous wavelet transform; computational shape analysis

The single amino acid replacement of Tyr52 with Leu drastically increased the activity of Lactobacillus pentosus NAD-dependent D-lactate dehydrogenase toward larger aliphatic or aromatic 2-ketoacid substrates by 3 or 4 orders of magnitude and decreased the activity toward pyruvate by about 30-fold, converting the enzyme into a highly active D-2-hydroxyisocaproate dehydrogenase.