Pharmacist-physician collaborative care for outpatients with left ventricular assist devices using a cloud-based home medical management information-sharing system: a case report

[Background] The standard anticoagulation therapy for patients implanted with left ventricular assist devices (LVADs) includes warfarin therapy. We developed a cloud-based home medical management information-sharing system named as LVAD@home. The LVAD@home system is an application designed to be used on iPad tablet computers. This system enables the sharing of daily information between a patient and care providers in real time. In this study, we reported cases of outpatients with LVADs using this system to manage anticoagulation therapy. [Case presentation] The patient, a man in his 40s with end-stage heart failure owing to non-ischemic dilated cardiomyopathy, underwent LVAD implantation and warfarin was started on postoperative day 1. He started to use LVAD@home to manage warfarin therapy after discharge (postoperative day 47). He sent his data to care providers daily. By using this system, the pharmacist observed his signs of reduced dietary intake 179 days after discharge, and after consulting the physician, told the patient to change the timing of the next measurement earlier than usual. On the next day, the prothrombin time-international normalized ratio increased from 2.0 to 3.0, and thus the dose was decreased by 0.5 mg. Four patients used this system to monitor warfarin therapy from October 2015 to March 2018. In these patients, the time in therapeutic range was 90.1 ± 1.3, which was higher than that observed in previous studies. Additionally, there were no thromboembolic events or bleeding events. [Conclusions] The cloud-based home management system can be applied to share real-time patient information of factors, including dietary intake that interact with warfarin. It can help to improve long-term anticoagulation outcomes in patients implanted with LVAD

Hyperlipidemia and Fat Absorption in Model Rats with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is frequently complicated by hyperlipidemia, which is closely related to the occurrence of atherosclerotic disorders. The small intestine, which absorbs dietary lipids, plays an important role in the regulation of the serum lipid concentrations. We confirmed morphological changes in small intestinal villi in the progression of diabetes mellitus and evaluated intestinal lipid absorption by the 13C-trioctanoin breath test in model rats with type 2 diabetes mellitus (OLETF rats). We measured the height of the intestinal villous epithelium and serially measured the expiratory 13CO2 concentration after the administration of 13C-trioctanoin in OLETF rats at the ages of 28, 36, and 44 weeks. The serum total cholesterol and triglyceride concentrations were significantly higher in the OLETF rats than in the control LETO rats. The height of the small intestinal villi was increased, indicating hyperplastic change. The 13CO2 concentration was significantly increased, suggesting hyperplasia of the small intestinal villi and enhancement of lipid absorption or increased total amount absorption. Excessive lipid absorption from the small intestine was suggested to be one of the causes of hyperlipidemia (particularly hypertriglyceridemia) complicating diabetes mellitus

Ultrasonographic echo intensity in the medial femoral cartilage is enhanced prior to cartilage thinning in women with early mild knee osteoarthritis

[Purpose] We aimed to determine whether altered cartilage echo intensity is associated with knee osteoarthritis (OA) severity and whether the alteration occurs before thinning of the femoral cartilage in knee OA. [Methods] The medial femoral cartilage thickness and echo intensity of 118 women aged ≥ 50 years were assessed using an ultrasound imaging device. Based on the Kellgren–Lawrence (KL) grade and knee symptoms, participants were classified into five groups: control (asymptomatic grades 0–1), early OA (symptomatic grade 1), grade 2, grade 3, and grade 4. Analysis of covariance, with adjusted age and height, and the Sidak post hoc test were used to assess the differences in cartilage thickness and echo intensity in knees with varying OA severity. [Results] The echo intensity on longitudinal images, equivalent to the tibiofemoral weight-bearing surface, was significantly higher in the grade 2 group than that in the control group (p = 0.049). However, no significant difference was noted in cartilage thickness (n.s.). In the grades 3 and 4 groups, cartilage thickness became thinner as OA progressed (p < 0.001 and p < 0.001, respectively). However, the cartilage echo intensity was not significantly enhanced compared with that of the grade 2 group (n.s.). There were no significant differences in the cartilage thickness and echo intensity between the early OA and control groups on the longitudinal images (n.s.). [Conclusions] The echo intensity of the medial femoral cartilage was high in patients with KL grade 2, without decreased thickness. Our findings suggested that higher echo intensity is a feature of early cartilage degeneration in mild knee OA. Further studies are needed to establish this feature as a useful screening parameter of early cartilage degeneration in knee OA. [Level of evidence] Level III

Fat Absorption and Morphological Changes in the Small Intestine in Model Mice with Hyperlipidemia (Apo E Deficiency)

In addition to abnormalities in lipid metabolism, the small intestine, which absorbs fat, plays an important role in the pathogenesis of hyperlipidemia. Using hyperlipidemia/arteriosclerosis models (apo E deficient mice), we measured morphological changes in the small intestinal villi, and investigated fat absorption using a 13C-trioctanoin breath test. In the apo E deficiency groups, the total cholesterol and triglyceride concentrations were higher than the values in the corresponding control groups. The height of the small intestinal villi was increased, showing a histological hyperplastic change. The concentrations of Δ13CO2 were significantly increased, suggesting the enhancement of fat absorption or an increase in the total volume of absorption. In apo E deficient mice, hyperplasia of the small intestinal villi and the enhancement of fat absorption were involved in the pathogenesis of hyperlipidemia. Excessive fat absorption in the small intestine may be one of the etiological factor for hyperlipidemia

Characteristics of Acute Cartilage Response After Mechanical Loading in Patients with Early-Mild Knee Osteoarthritis

This study determined whether the acute cartilage response, assessed by cartilage thickness and echo intensity, differs between patients with early-mild knee osteoarthritis (OA) and healthy controls. We recruited 56 women aged ≥ 50 years with Kellgren-Lawrence (KL) grade ≤ 2 (age, 70.6 ± 7.4 years; height, 153.7 ± 5.2 cm; weight, 51.9 ± 8.2 kg). Based on KL grades and knee symptoms, the participants were classified into control (KL ≤ 1, asymptomatic, n = 27) and early-mild knee OA groups (KL 1 and symptomatic, KL 2, n = 29). Medial femoral cartilage thickness and echo intensity were assessed using ultrasonographic B-mode images before and after treadmill walking (15 min, 3.3 km/h). To investigate the acute cartilage response, repeated-measures analysis of covariance (groups × time) with adjusted age, external knee moment impulse, steps during treadmill walking, and cartilage thickness at pre-walking was performed. A significant interaction was found at the tibiofemoral joint; after walking, the cartilage thickness was significantly decreased in the early-mild knee OA group compared to the control group (p = 0.002). At the patellofemoral joint, a significant main effect of time was observed, but no interaction was detected (p = 0.802). No changes in cartilage echo intensity at either the tibiofemoral or patellofemoral joints, and no interactions were noted (p = 0.295 and p = 0.063). As acute cartilage response after walking, the thickness of the medial tibiofemoral joint in the early-mild knee OA was significantly reduced than that in the control group. Thus, greater acute deformation after walking might be a feature found in patients with early-mild knee OA

Assessment of fore-, mid-, and rear-foot alignment and their association with knee symptoms and function in patients with knee osteoarthritis

OBJECTIVE: Hallux valgus, flatfoot, and rearfoot eversion are well-known major complications of knee osteoarthritis (OA). However, there is no consensus on the association between these foot malalignments and knee symptoms or function. Thus, this study aimed to examine the association between foot alignment and knee symptoms or function in patients with knee OA. METHODS: Female patients aged ≥ 50 years with symptomatic knee OA participated in this study. Knee symptoms and function were assessed using the Knee Society Scoring System (KSS). Hallux valgus, navicular/foot ratio, and leg heel alignment were used as the forefoot, midfoot, and rearfoot alignment indices, respectively. The navicular/foot ratio was defined as the ratio of the navicular height to the total foot length. We performed multiple linear regression analysis to examine the associations between foot alignment and knee symptoms or function. RESULTS: Seventy-eight participants participated our study. KSS symptom score was significantly associated with navicular/foot ratio (regression coefficient [β], -0.30; 95% confidence interval [CI], -109.2 to -20.5; P = 0.005), knee extensor strength (β, 0.32; 95% CI, 0.02 to 0.09; P = 0.004), and age (β, 0.24; 95% CI, 0.01 to 0.32; P = 0.036). KSS function score was not associated with foot alignments but with knee extensor strength (β, 0.40; 95% CI, 0.10 to 0.33; P = 0.001) and body mass index (β, -0.35; 95% CI, -2.82 to -0.66; P = 0.002). CONCLUSIONS: Knee symptoms were significantly associated with midfoot alignment in patients with medial knee OA. This suggests that lower navicular height in patients with medial knee OA may relate with the alleviation of knee symptoms. Key Points • In patients with medial knee OA, midfoot alignment was significantly associated with knee symptoms in patients with medial knee OA; however, knee function was not associated with foot alignment. • Lower navicular height in patients with medial knee OA may relate with the alleviation of knee symptoms

Understanding muscle coordination during gait based on muscle synergy and its association with symptoms in patients with knee osteoarthritis

Objective: We aimed to investigate the muscle coordination differences between a control group and patients with mild and severe knee osteoarthritis (KOA) using muscle synergy analysis and determine whether muscle coordination was associated with symptoms of KOA. Method: Fifty-three women with medial KOA and 19 control patients participated in the study. The gait analyses and muscle activity measurements of seven lower limb muscles were assessed using a motion capture system and electromyography. Gait speed and knee adduction moment impulse were calculated. The spatiotemporal components of muscle synergy were extracted using non-negative matrix factorization, and the dynamic motor control index during walking (walk-DMC) was computed. The number of muscle synergy and their spatiotemporal components were compared among the mild KOA, severe KOA, and control groups. Moreover, the association between KOA symptoms with walk-DMC and other gait parameters was evaluated using multi-linear regression analysis. Results: The number of muscle synergies was lower in mild and severe KOA compared with those in the control group. In synergy 1, the weightings of biceps femoris and gluteus medius in severe KOA were higher than that in the control group. In synergy 3, the weightings of higher tibial anterior and lower gastrocnemius lateralis were confirmed in the mild KOA group. Regression analysis showed that the walk-DMC was independently associated with knee-related symptoms of KOA after adjusting for the covariates. Conclusions: Muscle coordination was altered in patients with KOA. The correlation between muscle coordination and KOA may be attributed to the knee-related symptoms

Ultrasonographic echo intensity in the medial femoral cartilage is enhanced prior to cartilage thinning in women with early mild knee osteoarthritis

[Purpose] We aimed to determine whether altered cartilage echo intensity is associated with knee osteoarthritis (OA) severity and whether the alteration occurs before thinning of the femoral cartilage in knee OA. [Methods] The medial femoral cartilage thickness and echo intensity of 118 women aged ≥ 50 years were assessed using an ultrasound imaging device. Based on the Kellgren–Lawrence (KL) grade and knee symptoms, participants were classified into five groups: control (asymptomatic grades 0–1), early OA (symptomatic grade 1), grade 2, grade 3, and grade 4. Analysis of covariance, with adjusted age and height, and the Sidak post hoc test were used to assess the differences in cartilage thickness and echo intensity in knees with varying OA severity. [Results] The echo intensity on longitudinal images, equivalent to the tibiofemoral weight-bearing surface, was significantly higher in the grade 2 group than that in the control group (p = 0.049). However, no significant difference was noted in cartilage thickness (n.s.). In the grades 3 and 4 groups, cartilage thickness became thinner as OA progressed (p < 0.001 and p < 0.001, respectively). However, the cartilage echo intensity was not significantly enhanced compared with that of the grade 2 group (n.s.). There were no significant differences in the cartilage thickness and echo intensity between the early OA and control groups on the longitudinal images (n.s.). [Conclusions] The echo intensity of the medial femoral cartilage was high in patients with KL grade 2, without decreased thickness. Our findings suggested that higher echo intensity is a feature of early cartilage degeneration in mild knee OA. Further studies are needed to establish this feature as a useful screening parameter of early cartilage degeneration in knee OA. [Level of evidence] Level III