Chronic Kidney Disease As a Risk Factor of Stroke / 日本農村医学会雑誌

　　Chronic kidney disease (CKD) has recently been reported to be an independent risk factor for stroke. However, a detailed analysis was yet to be conducted according to stroke subtype. We attempted to determine the risk factors for stroke using data from the “specific health checkup” for metabolic syndrome conducted by the 9 hospitals affiliated with the Akita Prefectural Federation of Agricultural Cooperatives, and evaluate and determine the risk factors for stroke. There were 401 patients who had undergone metabolic syndrome checkups from 2007 and 2010 and suffered from stroke afterwards within 3 years after the screening. The controls were all 69,407 subjects who were screened during the same period. The predictors examined were sex, age, blood pressure, BMI, cholesterol values (HDL・LDL), history of diabetes mellitus, presence of atrial fibrillation, CKD, and drinking and smoking habits. Analysis was conducted using logistic regression. The risk factors for stroke as a whole were male sex, age, blood pressure, diabetes, atrial fibrillation, CKD, and smoking history. For cerebral infarction, the risk factors were male sex, age, blood pressure, diabetes, atrial fibrillation, CKD, and smoking habit. The risk factors for cerebral hemorrhage were age, blood pressure, and CKD. For subarachnoid hemorrhage, the risk factors were female sex, age, blood pressure, low HDLemia, and CKD. In conclusion, CKD is an independent risk factor for the 3 subtypes of stroke, and in particular plays an important role as a higher risk factor for cerebral hemorrhage. Smoking cessation and controls of blood pressure, diabetes and atrial fibrillation are the important measures for stroke prevention. In addition, the further intervention should also be targeted to those with the result of CKD revealed by specific health checkups.

Regional, institutional and individual factors affecting selection of minimally invasive nephroureterectomy in Japan: a national database analysis.

OBJECTIVES: To reveal individual, institutional and regional factors affecting selection of minimally invasive nephroureterectomy in Japan. METHODS: The Japanese Diagnosis Procedure Combination database was queried to retrieve cases of nephroureterectomy for pelvic or ureter malignancies carried out between 2007 and 2010. A multivariate logistic regression analysis with variables including age, sex, pre-existing comorbidities, tumor location, tumor-nodes-metastasis classification, academic status of hospitals, hospital volume, geographic region and year of surgery was modeled to evaluate predictors of carrying out a minimally invasive (including laparoscopic and minimum incision endoscopic) nephroureterectomy. RESULTS: Overall, 3863 open (58.2%), 2635 laparoscopic (39.7%) and 139 minimum incision endoscopic nephroureterectomy (2.1%) cases from 713 hospitals were identified. The proportion of minimally invasive procedures increased from 35.7% to 48.6%. Minimally invasive nephroureterectomy was the most frequently carried out in the Kinki and Chugoku regions (50.9% and 50.4%, respectively) compared with the least in the Kanto region (31.3%). Multivariate analysis showed that lower Charlson Comorbidity Index, lower tumor-nodes-metastasis stage, academic hospitals, higher operative volume centers, western regions of Japan and later year were independently associated with the use of minimally invasive nephroureterectomy. Age, sex and tumor location were not significant factors. CONCLUSIONS: Despite regional and institutional variations, the proportion of minimally invasive nephroureterectomy has gradually increased in Japan. Minimally invasive nephroureterectomy is more likely to be carried out in patients with low tumor stage and low risk at higher volume academic hospitals. Our findings provide fundamental data for future health policies to foster nationwide healthcare uniformity.

Risk Factors for Stroke in Akita Prefecture / 日本農村医学会雑誌

In Akita Prefecture, there are nine hospitals established by the Akita Prefectural Federation of Agricultural Cooperatives for Health and Welfare (Koseiren). Half of the stroke patients in the prefecture were treated in these Koseiren hospitals, and half of the mass screening projects for the prevention of cardio vascular diseases were undertaken by these hospitals. A retrospective cohort study was done using mass-screening data (age, sex, past history of diabetes mellitus, blood pressure, body mass index, smoking and drinking habits) of 175,033 cases stored at these hospitals from 1988 to 1999, and the prefecture-wide stroke data of 2,520 initial stroke events registered from 1988 to 2003. The number of stroke cases was broken down into 1,428 cases of cerebral infarction (57%, CI), 693 cases of cerebral hemorrhage (27%, CH) and 399 cases of subarachnoid hemorrhage (16%, SAH). The subjects were also divided into five age groups:30-49, 50-59, 60-69, 70-79 and 80-89. Blood pressure (BP) was classified into six categories according to the JNC 6 criteria. Risk factors were determined using the Cox analysis. The hazard ratio for CI and CH was increasing with advancing age. CI showed a higher hazard ratio in men than women (hazard ratio for men was 1.8). The hazard ratio was increasing as BP became higher in any of three stroke subtypes, and especially CH showed the strongest correlation with BP. Uncontrollable risk factors were very closely associated with the attack of CI. On the other hand, BP (controllable risk) was closely linked with the attack of CH. Our results showed the prevention of CI was not easy. Controlling BP may be the most effective strategy for preventing hemorrhagic stroke (CH and SAH).

[Epidemiology of stroke in the elderly]. / Az idoskori stroke epidemiológiája.

BACKGROUND: In the industrialized countries the very old stroke patient is more frequent than before. For the time being Japanese people have the highest expected lifespan, so the epidemiological features of stroke in the very old can be examined here quite easily. From a few publications with low case number it is known that in this group of patients the statistical characteristics of stroke is remarkably different from the younger ones. SUBJECTS AND METHODS: The subjects aged 85 or more years were selected from the Akita Stroke Registry with first-ever acute stroke from 1996 to 1998. RESULTS: 8046 cases were recorded. There were 7362 patients aged <85 years, and 684 patients aged > or =85 years (8.5%). Sex ratio (women/men) was 1.89 in the two age groups. In the population of Akita the crude incidence of first-ever stroke was 222/100,000/year, and 1085/100,000/year in the very old, who were characterized with relatively lower prevalence of stroke risk factors, except that of atrial fibrillation (26.9%) and cardiac diseases (34.2%). The stroke subtype distribution (cerebral infarction 73.2%, intracerebral haemorrhage 20.6%, subarachnoidal haemorrhage 6.1%) was significantly different from the one known in Japan. Mortality rates were considerably high, especially in the SAH group. The most powerful prognostic factor of death was the level of consciousness at the onset. The next in the order of predicting value was the SAH subtype. CONCLUSION: While people aged 85 years or more had relatively lower prevalence of cardiovascular risk factors, they suffered stroke with very high frequency, the evolved cerebrovascular event caused very severe symptoms and led to death with high rate. Implicitly this is illuminating the complexity of aging as a process, furthermore it increases the importance of prevention, and even more of the care and rehabilitation of acute stroke in this old age group.