Orthogeriatric co-management at a regional core hospital as a new multidisciplinary approach in Japanese hip fracture operation.

BACKGROUND: This study aimed to evaluate the effects of orthogeriatric co-management of hip fractures at a regional core hospital. METHODS: This study included patients with proximal hip fracture. Patients were divided into two groups, conventional multidisciplinary group I including patients attending the hospital between April 2015 and March 2016 and orthogeriatric group II including patients attending the hospital between April 2016 and March 2017, which were compared etrospectively. In the control group, the conventional multidisciplinary team treated patients as whole-body controls. In the intervention group, the newly recruited geriatricians performed physical examinations, laboratory tests, radioactive imaging, and physiological tests. Furthermore, they consulted ward pharmacists, rigorously conducted positive polypharmacy interventions , and evaluated the type and number of mediated drugs on admission. RESULTS: The number of medicated drugs significantly decreased from 6.03 ± 4.3 on admission to 5.50 ± 3.59 on discharge in group II, whereas group I did not show a significant decrease. Despite the more number of hospitalized patients in group II (166 patients) than in group I (126 patients), the recovery rate from postoperative urinary retention increased significantly from 57.8% (19/30) in group I to 84.3% (32/59) in group II (p = 0.049), while the incidence of aspiration pneumonia decreased from 7.1% (9/126) in group I to 2.49% (4/166) in group II (p = 0.08). The patients received six or more prescribed drugs on admission, and the number remained constant. However, the number of medicated drugs on discharge showed a marginally significant decrease from 6.03 ± 4.3 in group I to 5.50 ± 3.59 in group II (p < 0.05). CONCLUSIONS: Compared to the conventional multidisciplinary group, the orthogeriatric team contributed to reducing the number of multi-effect drugs and perioperative complications without negatively affecting mortality despite the increased number of patients. The in-hospital mortality rate did not change between the groups. The orthogeriatric program succeeded in preventing and treating perioperative complications.

Postoperative Urinary Retention in Japanese Elderly Males with a Femoral Neck or Trochanteric Fracture.

We assessed risk factors for postoperative urinary retention (UR) in elderly males with femoral bone fractures: 169 Japanese males (mean age 81.95 ± 1.19 years) who had undergone hip surgery at a municipal hospital (Toyama, Japan). A multiple logistic regression analysis was used to test possible risk factors for UR: age, body mass index, serum albumin, cognitive impairment, activities of daily living (ADL), and history of diabetes mellitus (DM). UR occurred in 24 (14.2%) of the 169 patients. A multivariate logistic regression analysis with age adjustment showed that ADL (odds ratio [OR] 3.88; 95% confidence interval [CI]: 1.2-12.5, p=0.023) was significantly associated with the development of UR, and a history of DM showed marginal significance for UR occurrence (OR 0.36, 95%CI: 0.11-10, p=0.064). These results suggests that ADL is a risk factor for UR development in elderly males who have undergone surgery for femoral neck or trochanter fractures.

Development of a Computer Application Used by Visiting Nurses, Physicians, and Patients/Caregivers to Prevent Indwelling Urinary Catheter Occlusion in the Community.

This study aimed to develop a computer application (software) for use by visiting nurses, physicians, and patients/caregivers, to support their care of long-term indwelling urinary catheters in the community. Development of this application involved: (1) confirmation of the intended purpose, users, and application construction; (2) establishment of the functional requirements for data sharing and communication among visiting nurses, physicians, and patients/caregivers; (3) design of three constituent "versions" of the application to be used by visiting nurses, physicians, and patients/caregivers, respectively; and (4) testing of the data sharing and communication functions. The application was designed to facilitate the prevention, assessment, and response to occlusion of indwelling urinary catheters during long-term use at home. This application is characterized by: (1) a unique design of three application "versions" that each reflect the specific care roles of its respective user group; (2) data sharing among the three groups according to their respective roles; and (3) the inclusion of caregivers as users. This article proposes a model that can inform the design of future applications for nursing professionals and patients and caregivers and provide a basis for future research on the development of healthcare applications supporting improvements in care.

Mortality and the Risk Factors in Elderly Female Patients With Femoral Neck and Trochanteric Fractures.

BACKGROUND: The main purpose of this study is to exhaustively explore risk factors, including age, gender, and several clinical indices, for mortality in elderly patients with femoral neck fracture and to evaluate some of them using survival analyses. METHODS: This was a retrospective study tracking 1 year for vital prognosis. Data were collected at post-operation from medical records of the cases. Survival analysis was conducted to investigate the risk factors for death, including albumin, urinary retention, activity of daily living (ADL), and cognitive disorder. RESULTS: We recruited 318 patients with a history of hip surgery carried out at Toyama Municipal Hospital, in which 39 patients died for 1 year after discharge. The results showed a significant decrease in survival rate in low albumin, positive urinary retention, and low ADL (P < 0.01, by log-rank test). The hazard ratios (95% confidence interval) of albumin, urinary retention, ADL, and cognitive disorder were 0.36 (0.19 - 0.69), 0.4 (0.2 - 0.8), 0.29 (0.15 - 0.58) and 0.65 (0.32 - 1.29), respectively. CONCLUSIONS: This study demonstrated that albumin, urinary retention and ADL were the important risk factors for mortality, and suggested that the postoperative management of albumin, urinary retention and ADL is important, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Risk factors for the development of aspiration pneumonia in elderly patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort.

Aspiration pneumonia (AP) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of AP in elderly patients with femoral neck fractures.We recruited 426 patients (age 84.9 ±â€Š7.4 years) with a history of hip surgery carried out at Toyama Municipal Hospital. AP occurred in 18 out of 426 cases (4.23%). Statistical test has found significant differences in age, gender, serum albumin level, and cognitive impairment, between AP and non-AP groups. Subsequently multiple logistic regression analysis was conducted to investigate the risk factors for AP, including age, gender, serum albumin, cognitive impairment, and activities of daily living (ADL). Adjusted odds ratio showed significant differences in age, gender, and serum albumin, whereas no significant differences were found in cognitive impairment and ADL.This study suggested that serum albumin seemed to be a risk factor for AP but were necessary to assess under adjustment of confounding factors, including age and gender. Monitoring serum albumin level seemed to be important for the postoperative management of AP, especially in elderly patients receiving surgery of femoral neck and trochanteric fractures.

Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort.

Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ±â€Š7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Proteomic analysis of a rare urinary stone composed of calcium carbonate and calcium oxalate dihydrate: a case report.

The objective of the present study was to investigate the matrix protein of a rare urinary stone that contained calcium carbonate. A urinary stone was extracted from a 34-year-old male patient with metabolic alkalosis. After X-ray diffractometry and infrared analysis of the stone, proteomic analysis was carried out. The resulting mass spectra were evaluated with protein search software, and matrix proteins were identified. X-ray diffraction and infrared analysis confirmed that the stone contained calcium carbonate and calcium oxalate dihydrate. Of the identified 53 proteins, 24 have not been previously reported from calcium oxalate- or calcium phosphate-containing stones. The protease inhibitors and several proteins related to cell adhesion or the cytoskeleton were identified for the first time. We analyzed in detail a rare urinary stone composed of calcium carbonate and calcium oxalate dihydrate. Considering the formation of a calcium carbonate stone, the new identified proteins should play an important role on the urolithiasis process in alkaline condition.

Cyclooxygenase 2 and prostaglandin E2 regulate the attachment of calcium oxalate crystals to renal epithelial cells.

OBJECTIVE: To determine the roles of endogenous cyclooxygenase 2 and prostaglandin E(2) in crystal-cell binding, which is considered to be an important step in the development of intratubular nephrocalcinosis. METHODS: An expression plasmid for human cyclooxygenase 2 was introduced into Madin-Darby canine kidney cells using the lipofection method. Cyclooxygenase activity was measured using thin-layer chromatography, and the prostaglandin E(2) concentration was determined with an enzyme immunoassay. In addition, crystal attachment was evaluated with a liquid scintillation counter using [(14)C] calcium oxalate monohydrate crystals, and immunohistochemistry and an enzyme immunoassay were used to analyze and quantify the expression of hyaluronan, a crystal-binding molecule. RESULTS: Cyclooxygenase 2-overexpressing Madin-Darby canine kidney cells produced about 10-fold more prostaglandin E(2) than wild-type Madin-Darby canine kidney cells, and their hyaluronan production was also upregulated. The attachment of calcium oxalate monohydrate crystals to cyclooxygenase 2-overexpressing Madin-Darby canine kidney cells was significantly reduced compared with their attachment to wild-type and mock-transfected Madin-Darby canine kidney cells. Pre-incubation of the cyclooxygenase 2-overexpressing cells, as well as the mock-transfected and wild-type cells with the cyclooxygenase 2 selective inhibitor etodolac, increased the cellular attachment of calcium oxalate monohydrate crystals in a dose-dependent manner. CONCLUSIONS: These findings suggest that cyclooxygenase 2 expression and the resultant increase in endogenous prostaglandin E(2), leading to increased hyaluronan production, help to prevent nephrocalcinosis by inhibiting the attachment of calcium oxalate monohydrate crystals to the surface of renal epithelial cells.

[Outlook for recurrence prevention from the viewpoint of the guidelines on urolithiasis].

In Japan, the number of patients with urolithiasis has continued to increase at a faster rate, with a lifetime morbidity in 2005 of 15.1% for males and 6.8% for females, possibly due to : 1) westernization of dietary habits and lifestyle, 2) improvement of diagnostic technologies (CT and ultrasound examination), and 3) aging of the population. Additionally, this disease has a higher recurrence rate ; for example, approximately 50% for calcium-containing calculi. The guidelines on urolithiasis consist primarily of the guidelines for treatment and recurrence prevention, and the items concerning recurrence prevention were added in the 2007 updated Guidelines on Urolithiasis by the European Association of Urology (EAU) and the American Urological Association (AUA) (EAU/AUA guidelines). These facts reflect the importance of recurrence prevention. On the other hand, the Japanese guidelines on urolithiasis are now being revised and will adopt the form of "clinical questions". This paper provides an overview of the examination methods for recurrence, lifestyle guidance, and drug therapies based on the current guidelines for diagnosis and treatment of urolithiasis as well as the points for clinical questions to be included in the revised guidelines for a deeper understanding and, consequently, return to routine clinical practice.

[The anxiety and types of problems encountered by homecare patients during an intermittent self-catheterization].

The aim of this study was to clarify why a homecare patient had an anxiety and the type of difficulties while having an intermittent self-catheterization at home. We used a questionnaire survey to conduct an oral interview for 25 homecare patients, who regularly had an intermittent self-catheterization. The survey results were codified into single phrase units of meaning, and then separated into categories. The results revealed that 70 to 80% of patients who had an intermittent self catheterization in their own homes experienced an anxiety and encountered difficulties during the process. The findings emphasized the importance of providing a sort of support for homecare patients when they have an intermittent self-catheterization for the first time, as well as the importance of providing continued support until the patients are comfortable with the procedure. For a future support, these patients' anxiety need to be reduced and difficulties related to an intermittent self catheterization resolved during an outpatient visit.

[Self purchase of catheter supplies and the hardship associated with urinary homecare patients].

The aim of our study was to clarify how catheter products are purchased by urinary homecare patients and to find problems associated with such purchases. We conducted a survey using a self-made questionnaire for 26 catheterized patients from Prefecture A, who were regular outpatients of the urology department. The results indicated that 17 patients(65. 4%)purchased catheter supplies on their own(13 males and 4 females, the mean age was 57. 9 years). The products purchased by the 26 patients were diverse including urine bags, syringes, catheters and tissues paper. Seven of the 17 patients(41%)responded that purchasing catheter supplies on their own was difficult, and 8(47%)responded that purchasing catheter supplies was an economic burden for them. The cost of purchasing catheter supplies varied greatly among the patients, and the price range was from 400 yen to 12, 000 yen. The cost was generally associated with the feelings of economic stress: it happens every month; it is a burden for some patients who need them for life time.

[A study of the goods supply system from hospital to outpatients with intermittent self-catheterization(ISC)].

OBJECTIVES: This study investigated the current status of goods supplied by medical facilities to outpatients practicing ISC. METHODS: The status of goods supplied was investigated by interviewing 4 medical facilities and 26 outpatients practicing ISC, using a questionnaire. RESULTS: 1. Of all goods supplied for use by outpatients practicing ISC, 53. 0%were supplied by medical facilities. The outpatients bought some goods required for ISC by himself. Moreover, some goods were supplied by prescription. 2. When a hospital was consulted, while there were those to whom goods are not supplied from a hospital, there were those to whom much kinds and quantity are supplied from the hospital. As for the patient to whom many kinds and the goods of quantity are supplied, goods expense formed about 70% of ISC administration fee. DISCUSSION: In order to establish goods feed system, it was necessary to examine a common knowledge of the structure of goods supply to doctors or nurses and the validity of the ISC administration fee system from now on.

[Diet therapy and life guidance to prevent calcium stones].

Urolithiasis patients have a low continuation rate with regard to visiting the hospital and undergoing periodic check-ups following therapy. The increased Westernization of diets has played a major role in its onset, and it is believed to be a lifestyle disease. Therefore, the prevention of relapse is difficult without improving the patients' lifestyle and eating habits, and it has been defined as a disease with an extremely high relapse rate. On the other hand, it is believed that the opportunity for periodic visits to the hospital and check-ups can be assured by continuously performing careful dietary interventions appropriate for each patient and by educating patients about the disease, thereby contributing to the prevention of relapses of urolithiasis.

[Combination chemotherapy of docetaxel and UFT against hormone refractory prostate cancer].

Docetaxel-based chemotherapy has been shown to be effective and well tolerated by Japanese patients with metastatic hormone-refractory prostate cancer (HRPC). This study was undertaken to assess the feasibility of docetaxel in combination with UFT (a combination of tegafur and uracil) in Japanese patients with HRPC. Ten patients aged 60-86 years with HRPC, who were pre-treated with hormonal therapy and expected to have more than 3 month survival and without major organ dysfunction, were included in this study. Treatment consisted of docetaxel 70 mg/m2 every 3 weeks plus UFT 260 mg/m2 /day. The primary end point was prostate-specific antigen (PSA) response, and the secondary end points included progression-free survival and toxicity. Nine patients were evaluable for efficacy and toxicity. The PSA response rate was 50% (1 CR and 4 PR). The most common non-hematological adverse events (of any grade) possibly related to treatment were neutropenia and anorexia. Grade 3/4 neutropenia and anorexia occurred in 50 and 20% of patients, respectively. The combination of docetaxel and UFT was feasible and active in Japanese patients with HRPC, with a manageable adverse-event profile similar to that observed in lung cancer chemotherapy.

[Evolution of strategy to measure urinary supersaturation].

Urinary stones have an estimated lifetime morbidity of 15.1% in males and 6.1% in females ; in other words, one out of seven males and one out of fifteen females are affected with this disease at least once in their life. Previously, we reported a simple and easy method using microplates to measure the metastable limit (ML), which indicate the upper limit of supersaturation dissolution. In this study, we examined the usability of this microplate method. We confirmed that ML is correlated with the urinary calcium concentration in healthy subjects, single stone formers (SF), and recurrent stone formers (RSF). There was no significant difference between healthy subjects and RSF in urinary magnesium concentration, and ML was found to be correlated with urinary the concentration of oxalate and citrate acid in healthy subjects only. These results suggest that ML is a simple and easy way to measure the urinary calcium level and that ML could be a useful test item in outpatient settings as a convenient indicator for preventing recurrence of urinary stones in the future.

[Renal protective effects of erythropoietin on ischemic reperfusion injury].

We reexamined the conditions of tissue disorders resulting from temporary ischemia of the organs as well as changes in tissue function and the effects on the preservation of renal function over time by using rat models in order to clinically utilize erythropoietin, which has inhibitory effects on ischemia-reperfusion disorders. In 8- to 9-week-old Wister male rats, after the right kidney had been resected under general anesthesia, the left renal artery was clamped to inhibit the blood flow for 45 minutes. At 30 minutes before inhibiting the blood flow and after releasing the inhibited blood flow, 100 U/kg of recombinant human erythropoietin (rhEPO) was administered via the inferior vena cava and the abdominal cavity, and then the tissues and blood samples were extracted at 6 hours and 24 hours after the release. The renal tissue specimens were evaluated for apoptosis and renal function using hematoxylin eosin staining and TUNEL staining. Changes in the emergence of active oxygen were investigated by using blood samples. The degree of renal dysfunction was evaluated by measuring neutrophil gelatinase-associated lipocalin (NGAL) in the spot urine samples. The changes in the serum creatinine level, showed that the renal function was preserved with a significant difference in the rhEPO administration group. The liver deviation enzymes clearly decreased in the rhEPO administration group. Active oxygen did not change before and after the ischemia-reperfusion nor was it changed by rhEPO administration. Apoptosis was inhibited by rhEPO administration. No direct effects of rhEPO administration on the emergence of active oxygen were observed. The administration of rhEPO, was suggested to help preserve the renal function in marginal donors with a longer agonal stageby effectively.

A case of second renal transplantation with acute antibody-mediated rejection complicated with BK virus nephropathy.

We reported a 40-year-old female case of second renal transplantation with antibody-mediated rejection (AMR) complicated by BK virus nephropathy. She started hemodialysis (HD) at the age of 17 because of IgA nephropathy. At the age of 18, she underwent living-donor kidney transplantation from her father, but two and a half years after transplantation, she developed chronic rejection. This time, she received cadaveric renal transplantation under the negative cross-match (AHG-LCT), and HLA-AB 1 mismatch and -DR 1 mismatch. Immunosuppressive therapy was initiated using the following four immunosuppressants: methylprednisolone, mycophenolate mofetil, cyclosporine, and basiliximab. However, renal graft showed delayed function, the biopsy showed glomerulitis (g2), endarteritis (v1), and cellular infiltration (ptc3) consisting mainly of mononuclear cells in the peritubular capillary with diffusely positive C4d and anti-SV 40 large T-antigen-positive renal tubular epithelial cells on post-operative day 19. The donor-specific antibody for HLA-B46 was proven by the LAB screen method. We performed plasma exchange three times and administered immunoglobulin (15 g in total). Then, methylprednisolone pulse therapy was added, and the serum creatinine (SCr) levels gradually decreased. On post-operative day 44, the patient was removed from HD and was discharged with SCr level of 3.3 mg/dL.

Renal protective effects of erythropoietin on ischemic reperfusion injury.

While the problem of organ shortage has not yet been solved, the number of patients who need to be treated with dialysis due to end-stage renal disease (ESRD) is increasing each year. With the aim of eliminating dialytic therapy as much as possible, the opportunities for organ donation from expansive criteria donor (ECD) or marginal donors due to cardiac death have been increasing. With the purpose of extracting organs in a state in which the function is preserved as much as possible, we reexamined the conditions of tissue disorders resulting from temporary ischemia of the organs as well as changes in tissue function and the effects on the preservation of renal function over time by using rat models in order to clinically utilize erythropoietin, which has inhibitory effects on ischemia-reperfusion disorder, as has been conventionally reported. With 8- to 9-week-old Wister male rats, after the right kidney had been resected under general anesthesia, the left renal artery was clamped to inhibit the blood flow for 45 min. At 30 min before inhibiting the blood flow and after releasing the inhibited blood flow, 100 U/kg of recombinant human erythropoietin (rhEPO) was administered via the inferior vena cava and the abdominal cavity, and then the tissues and blood samples were extracted at 6 and 24 h after the release. The renal tissue specimens were evaluated using H&E staining and TUNEL staining in order to observe differences in the expression of apoptosis as well as the renal function and changes in the emergence of active oxygen were investigated by using samples that had been obtained from drawn blood. Moreover, we examined the degree of renal dysfunction by means of neutrophil gelatinase-associated lipocalin (NGAL) in the spot urine samples. The changes in renal function, which were observed according to the serum creatinine level, showed that the renal function was preserved with a significant difference in the rhEPO administration group. The liver deviation enzymes, which had also shown increases in the serum as well as the occurrence of renal dysfunction, showed clear decreases in the serum, even though changes with a significant difference were not observed in the rhEPO administration group. The active oxygen did not show changes before and after ischemia-reperfusion nor changes due to the rhEPO administration. When examining the status of apoptosis in the tissues, apoptosis was shown to be inhibited due to the rhEPO administration. It is believed that the main preservation effects of rhEPO are the elimination of cytopathy/cell death, as derived from the resulting ischemic condition that extends to the target organ before ischemia occurs. In this examination, no direct effects of rhEPO administration on the emergence of active oxygen were observed. It is therefore suggested that there is a possibility of preserving the renal function in marginal donors with a longer agonal stage by effectively using rhEPO.

Inhibitions of urinary oxidative stress and renal calcium level by an extract of Quercus salicina Blume/Quercus stenophylla Makino in a rat calcium oxalate urolithiasis model.

OBJECTIVES: To clarify the mechanism of Urocalun, an extract of Quercus salicina Blume/Quercus stenophylla Makino (QS), in the treatment of urolithiasis. METHODS: Rat calcium oxalate urolithiasis was induced by oral administration of ethylene glycol and the vitamin D3 analog alfa-calcidol for 14 days. QS extract was repeatedly given to rats. After the last administration, biochemistries in urine and plasma, renal calcium, and urinary malondialdehyde (an oxidative stress marker) were measured. RESULTS: Ethylene glycol and alfa-calcidol treatment increased urinary malondialdehyde and renal calcium levels. This increase was significantly suppressed by the administration of QS extract, suggesting that the inhibition of renal calcium accumulation by QS extract is due to its antioxidative activity. CONCLUSIONS: These findings suggest that the antioxidative activity of QS extract plays a role in the prevention of stone formation and recurrence in urolithiasis.

cDNA macroarray analysis of genes in renal epithelial cells exposed to calcium oxalate crystals.

Kidney stone formation is a complex process, and numerous genes participate in this cascade. The binding and internalization of calcium oxalate monohydrate (COM) crystals, the most common crystal in renal stones by renal epithelial cells may be a critical step leading to kidney stone formation. Exposure to COM crystals alters the expression of various genes, but previous studies on gene expression have generally been limited. To obtain more detailed insight into gene expression, we examined gene expression profiles in renal epithelial cells exposed to COM crystals using cDNA macroarray. NRK-52E cells were exposed to COM crystals for 60 and 120 min. Poly (A)(+) RNA was isolated and converted into (32)P-labeled first-strand cDNA, then the cDNA probe was hybridized to the membrane. Hybridization images were scanned and the signal intensities were quantified. Expression of mRNA of 1,176 genes was analyzed with global sum normalization methods. Exposure to COM crystals altered the expression of some of the genes reported previously. Furthermore, novel genes were also identified. Over 20 genes were found to be regulated at least twofold. We performed a large-scale analysis of gene expression in renal epithelial cells exposed to COM crystals, and identified the genes differentially regulated. cDNA macroarray is a useful tool for evaluating gene expression in urolithiasis research.