Biochemical and body composition analysis of nocturia in the elderly.

AIMS: Nocturia is a common symptom in the elderly, and various contributing factors have been suggested. Therefore, in order to investigate which factors are strongly related to occurrence of nocturia, we performed a suite of examinations. METHODS: One hundred eighty volunteers were divided into three groups: a young adult control group (60 healthy persons without nocturia), an elderly control group (60 healthy persons with a low mean frequency of nocturnal urination, i.e., twice per night) in the elderly.

Prognosis of bedridden patients with end-stage renal failure after starting hemodialysis.

BACKGROUND: The mean age of starting hemodialysis (HD) in patients with end-stage renal failure is gradually increasing in Japan. It is not uncommon for HD to be commenced in bedridden elderly patients who cannot give informed consent, because of brain damage. However, we have not been able to provide useful advice to their families because there was no relevant information available about the prognosis of bedridden patients on HD. Therefore, we examined the prognosis of bedridden HD patients. METHODS: Two hundred and nineteen patients who received HD were enrolled. These subjects were divided into five groups; (aged <50, 50-59, 60-69, 70-79, and >or=80 years at the commencement of HD), and we compared the overall prognosis between bedridden and nonbedridden patients, as well as that for each age group. RESULTS: There were 76 bedridden patients among the 219 HD patients, and the main cause of their bedridden state before starting HD was cerebrovascular disease. The 50% survival time after the start of HD was 120 months for the nonbedridden patients versus 56 months for bedridden patients. However, the mean (+/-SD) age of the bedridden patients was higher than that of nonbedridden patients (70 +/- 13 versus 64 +/- 14 years). In patients under age 50 years at the start of dialysis, the survival rate was lower in the bedridden than in the nonbedridden patients, but there were no differences between survival rates for bedridden and nonbedridden patients in the other four age groups. CONCLUSIONS: The prognosis of HD patients is poor compared with the general life expectancy of the Japanese population, but whether these patients are bedridden or not has little influence on their survival.

Effects of walking exercise on nocturia in the elderly.

We investigated whether nocturia in the elderly was improved by walking exercise, which involved walking rapidly for 30 min or more in the evening or night for 8 weeks. A questionnaire related to micturition and exercise, blood pressure, body composition analysis, blood biochemistry tests, and urinalysis were performed before and after 8 weeks of exercise to investigate the effects of walking. Thirty men (71 years old on average) continued the walking exercise for long enough to undergo evaluation. The number of episodes of nocturia decreased significantly (p < 0.001) from 3.3 +/- 0.7 to 1.9 +/- 0.8 after 8 weeks of walking exercise. The daytime urinary frequency, blood pressure, body weight, body fat ratio, edema ratio, serum catecholamines, triglycerides, and total cholesterol were also decreased. After 8 weeks of exercise, 20 of the subjects (67%) stated that sleep was deeper than before exercise. Assessment of the overall improvement showed that excellent or good results were obtained in 18 patients (60%). The main factor related to the influence of walking exercise on nocturia was that sleep became deeper, which increased the arousal threshold bladder volume. Walking exercise may also have a preventive effect on lifestyle-related diseases.

Change of blood viscosity and urinary frequency by high water intake.

Physicians recommend a high water intake to prevent cerebral infarction by decreasing blood viscosity. However, there is no evidence that high water intake decreases viscosity, although it increases urinary frequency. Therefore, we investigated the change of blood viscosity and urinary frequency by high water intake. We examined the change of blood viscosity after acute water intake, the circadian rhythm of blood viscosity, and the change of early morning blood viscosity and urinary frequency after high water intake for 1 week in healthy volunteers aged 31-75 years. Blood viscosity decreased transiently by acute water intake, but remained within the range of its circadian rhythm. Morning blood viscosity did not alter by high water intake for 1 week, although urinary frequency increased. Because excessive water intake increases urinary frequency without decreasing blood viscosity, a high water intake should not be recommended in persons with urinary frequency.

Intravesical instillation of bacille Calmette-Guérin for superficial bladder cancer: cost-effectiveness analysis.

OBJECTIVES: Frequent recurrence of superficial bladder cancer is a major problem that impairs patients' quality of life. We studied the current treatment of superficial bladder cancer, including the economic aspects of intravesical instillation. METHODS: A total of 138 superficial bladder cancers were assessed. The tumor characteristics and treatments were investigated during a mean observation period of 86 months by univariate and multivariate analyses. The costs associated with intravesical instillation of bacille Calmette-Guérin (BCG) and its side effects were subjected to cost-effectiveness analysis. RESULTS: Tumor histologic examination revealed grade 1 in 21 lesions, grade 2 in 60 lesions, grade 3 in 40 lesions, and unclassified in 17 lesions. The pathologic stage was Stage Ta in 85 lesions, T1 in 47 lesions, and Tis in 6 lesions. Univariate and multivariate analyses showed that intravesical instillation of BCG was the most significant factor preventing recurrence, and intravesical chemotherapy had no impact on recurrence. The 5-year recurrence-free survival rate was 78% and 28% for tumors with and without BCG instillation, respectively. The cost-effectiveness ratio of BCG instillation was approximately 3900 dollars/5-yr recurrence-free period. CONCLUSIONS: Our results have indicated that BCG is an effective adjuvant therapy after transurethral resection of superficial bladder cancer in the current medical environment.

A gap junction blocker inhibits isolated whole bladder activity in normal rats and rats with partial bladder outlet obstruction.

We examined the effect of 18alpha-glycyrrhetinic acid (18alpha-GA), a gap junction blocker, or propiverine hydrochloride on the activity of isolated whole bladders obtained from intact rats and rats with partial bladder outlet obstruction (BOO). Thirty-two female Sprague-Dawley rats were divided into an intact group and a BOO group. The whole bladder was harvested from each rat and isovolumetric cystometry was performed in Krebs solution. Changes of bladder activity were recorded after addition of 18alpha-GA or propiverine hydrochloride to the perfusate. Propiverine hydrochloride inhibited the amplitude and duration of contraction in both intact and BOO groups. Propiverine hydrochloride also reduced the baseline bladder pressure in the BOO group, but not in the intact group. In contrast, 18alpha-GA inhibited the amplitude and duration of bladder contraction, and also reduced the baseline pressure, in both intact and BOO groups. BOO bladders showed inhibition of the amplitude and duration of bladder contraction at lower concentrations of 18alpha-GA than intact bladders. A gap junction blocker suppressed the in vitro activity of BOO bladders more effectively than that of intact bladders. Therefore, inhibition of intercellular communication in the bladder via gap junctions may be useful for treating detrusor overactivity, as well as propiverine hydrochloride.

Inhibitory effect of the nucleus reticularis pontis oralis on the pontine micturition center and pontine urine storage center in decerebrate cats.

The influence of the nucleus reticularis pontis oralis (PoO) on the pontine micturition center (PMC) and pontine urine storage center (PUSC) was examined in decerebrate cats by electrical and chemical stimulations of the PMC, PUSC or PoO. Microinjection of carbachol into the rostral and dorsolateral part of the PoO rapidly inhibited reflex micturition and external urethral sphincter (EUS) activity. After confirming the inhibition of reflex micturition and EUS activity by microinjection of carbachol into the PoO, intravenous injection of atropine sulfate or its microinjection into the PoO recovered both reflex micturition and EUS activity. Microinjection of carbachol into the PMC evoked micturition and then inhibited reflex micturition, but intravenous injection of atropine or its microinjection into the PoO recovered reflex micturition. After confi rming the inhibition of reflex micturition and EUS activity by microinjection of carbachol into the PoO, electrical stimulation of the PUSC enhanced EUS activity, but electrical stimulation of the PMC failed to evoke micturition. However, electrical stimulation of the PMC evoked micturition after microinjection of atropine into the PoO. These results suggest that the PoO strongly inhibits the PMC and less strongly inhibits the PUSC. Therefore, the PoO seems to be the pontine micturition inhibitory area.

Aberrant halt of syringe pump motion: an improved system to prevent false setting of the syringe.

A syringe pump is used to inject precise doses of drugs having a strong action; for example, vasoactive drugs. Unexpected and undetected halt of a syringe pump can lead to potentially life-threatening complications. We experienced a sudden halt in the movement of a syringe pump (Terufusion syringe pump; Terumo, Tokyo, Japan) in two patients while administering norepinephrine in the intensive care unit (ICU). Fortunately, the patients had only transient hypotension, which was immediately detected and promptly treated, without any untoward sequelae. As a result of the occurrence of such cases, we conducted a detailed investigation of the causes of this sudden halt in the syringe pump. We could not reproduce the aberration of the syringe pump and thus could not specify the cause in the first patient. In the second patient, however, a false setting on the syringe was suspected to be the cause of the problem. In order to prove this, we tried to reproduce the situation where a syringe pump, due to a false syringe setting, abruptly terminated while giving a "syringe loss" warning, after a period of precise functioning. Once we had determined how a false setting of the syringe could occur without the syringe pump giving off an alarm from the onset, we collaborated with the Terumo Company to revise their current instruction manual to incorporate this as a warning. We also helped in the development of a new model, including a new safety feature that would prevent a false setting of the syringe from occurring at all. This new model was released in December 2003.

Calcium oxalate saturation in dialysis patients with and without primary hyperoxaluria.

Calcium oxalate supersaturation of the blood is associated with deposition of crystals in various tissues. We measured the serum levels of oxalate, citrate, calcium, and magnesium to estimate their saturation in 112 hemodialysis patients without primary hyperoxaluria and two boys with primary hyperoxaluria. Serum levels of oxalate and citrate were determined by high-performance capillary electrophoresis, while calcium and magnesium were measured by ICP spectroscopy. The serum levels of oxalate, citrate, calcium, and magnesium were 44.9+/-16.5, 138.1+/-54.9 micromol/l, 2.30+/-0.28, and 1.07+/-0.18 mmol/l, respectively, while the levels in patients with primary hyperoxaluria were 83.9+/-34.3, 197.9+/-63.5 micromol/l, 2.53+/-0.15, and 1.14+/-0.34 mmol/l, respectively. Serum calcium oxalate saturation (SS), as calculated by the Equil program, was significantly correlated with the serum oxalate level. Most patients showed metastable supersaturation (1

Major factors modulating the serum oxalic acid level in hemodialysis patients.

Ascorbic acid overload and vitamin B6 deficiency have been implicated in the development of hyperoxalemia in dialysis patients, but there is still disagreement about this. Hemodialysis patients who are exposed long-term hyperoxalemia may develop secondary oxalosis with an increased risk of cardiac, vascular, and bone disease, and thus may benefit from maintaining a low serum oxalic acid level. In 452 hemodialysis patients, the serum level of oxalic acid was 47.2 +/- 22.9 micromol /l before and 16.9 +/- 10.5 micromol/l after a 4-hour dialysis session, while the ascorbic acid levels were 39.0 +/- 92.7 micromol/l and 6.5 +/- 18.6 micromol/l, the glycolic acid levels were 7.3 +/- 10.1 micromol/l and 0.6 +/- 2.3 micromol/l, and the citric acid levels were 141.3 +/- 54.7 micromol/l and 117.6 +/- 37.2 micromol/l, respectively. Most patients (65.3 percent) had low serum ascorbic acid levels (less than 10 micromol/l) before hemodialysis. The serum level of oxalic acid [Ox] showed a significant positive correlation with the levels of ascorbic acid [AA], glycolic acid [Gly], and creatinine [Cre]: [Ox] = 21.711 + 0.181 x [AA] + 0.174 x [Gly] + 0.171 x [Cre], (all micromol/l, p less than 0.05). In 124 dialysis patients, the 4-pyridoxic acid level was 8.9 +/- 19.6 micromol /l before and 3.9 +/- 8.8 micromol/l after dialysis, and it was not correlated with oxalic acid or glycolic acid. Most dialysis patients (65.3 percent) had low serum levels of ascorbic acid, but a subgroup of patients (12 percent) had high serum ascorbic acid levels (more than 100 micromol/l) associated with hyperoxalemia (88.2 +/- 24.5 micromol/l). High-dose vitamin C supplementation may aggravate hyperoxalemia in hemodialysis patients, so attention should be paid to avoiding this risk.

New blood volume monitoring method for hemodialysis: A-V pressure gradient measurement by synchronized one-point reading.

During hemodialysis, rapid ultrafiltration often causes symptomatic hypotension. To predict the occurrence of volume-dependent hypotension as early as possible, continuous hematocrit monitoring with the Crit-Line noninvasive monitor has been widely used to measure blood volume changes during hemodialysis. As another potential method of monitoring blood volume variations, we studied blood viscosity, which is theoretically associated with the pressure gradient across the dialyzer. Blood viscosity (calculated by the Hugen-Poiseuille formula) is a major determinant of the blood flow rate and is associated with the pressure difference between the postpump arterial (A) and venous (V) pressures. The A-V pressure gradient fluctuates due to pump pulsation, so we minimized this noise by always reading the pressure gradient at the same point out of 1400 partitions on the rotary pump. To test this synchronized one-point reading method, the A-V pressure gradient was measured using 3 different xanthan gum solutions and was found to be linearly proportional to the model blood flow rate. In an experimental dialysis system using a xanthan gum solution (300 mg/L), the A-V pressure gradient showed a gradual linear increase along with the ultrafiltration rate up to 1 L/h as the viscosity slowly increased in the dialyzer. The changes of blood volume shown by this method were significantly correlated with data obtained using the Crit-Line in 8 patients undergoing hemodialysis. This simple and inexpensive method may allow monitoring of blood volume changes and thus provide data that are beneficial for fluid management in hemodialysis patients suffering from clinical dialysis intolerance.

Urinary saturation and risk factors for calcium oxalate stone disease based on spot and 24-hour urine specimens.

In 222 random spot urine specimens, the calcium concentration and calcium oxalate saturation [DG(CaOx)] were significantly higher among stone formers than among non-stone formers, while the citrate and creatinine-corrected citrate concentrations were lower. In 188 24-hour urine specimens, magnesium excretion was lower among stone formers than non-stone formers, while the creatinine-corrected calcium concentration and DG(CaOx) were higher. Among stone formers, there was no gender difference in the urinary concentrations of calcium, oxalate, citrate, magnesium, and DG(CaOx), but the creatinine-corrected calcium, citrate, and magnesium concentrations were higher in women, as well as 24-hour citrate excretion. The levels of calcium and oxalate have a major influence on DG(CaOx), while citrate and magnesium levels have a minor influence. DG(CaOx) was correlated with calcium and oxalate excretion, as well as with the creatinine-corrected calcium and oxalate concentrations. Approximately 5% of 24-hour urine specimens showed critical supersaturation, 80% showed metastable supersaturation, and 15% were unsaturated. Hypercalciuria or hyperoxaluria was fairly common (30% and 40%) in critically supersaturated urine, while it was less common (22.4% and 8.6%) in metastably supersaturated urine and was not detected in unsaturated urine. Hypocitraturia and/or hypomagnesiuria was more common (63.8-80%) at any saturation. The urinary calcium, oxalate, and citrate concentrations, as well as the creatinine-corrected calcium, oxalate, citrate, and magnesium concentrations and DG(CaOx), showed a significant correlation between 57 paired early morning spot urine and 24-hour urine specimens. The creatinine-corrected calcium and citrate concentrations of the early morning urine specimens were significantly correlated with the levels of calcium and citrate excretion in the paired 24-hour urine specimens. In conclusion, no parameter other than urinary saturation gives more than a vague indication of the risk of lithogenesis, so DG(CaOx) in either early morning urine or 24-hour urine specimens appears to be the best predictor of stone risk. Finally, the creatinine-corrected calcium and citrate concentrations in early morning urine can be used as a substitute for measuring 24-hour excretion.

Transabdominal vesical sonography of urethral syndrome and stress incontinence.

BACKGROUND: Transabdominal ultrasonography was used to study the bladder neck morphology in women with urethral syndrome or stress urinary incontinence, in order to determine the ultrasonographic findings of these conditions. METHODS: A total of 210 female patients with a normal bladder, asymptomatic trigonitis, urethral syndrome, and stress incontinence were studied. The mucosal thickness around the bladder neck, the length of the anterior base plate of the bladder, and the anteroposterior vesical wall angle (APVA) at the bladder neck were measured on sagittal transabdominal vesical ultrasonograms with the patient in the supine position. RESULTS: Patients with asymptomatic trigonitis or urethral syndrome had thicker mucosa around the bladder neck than the subjects with a normal bladder, and the subjects with stress incontinence had normal mucosa. The APVA was 158 +/- 17 (mean +/- SD) degrees in the subjects with a normal bladder. It was smaller in symptomatic patients and decreased to 109 +/- 10 degrees in those with conservative therapy-resistant incontinence. The anterior edge of the vesical base plate was visible approximately 2 cm from the bladder neck in subjects without incontinence, while it tended to be absent in patients with incontinence and an APVA of less than 126 degrees. CONCLUSION: A small APVA appears to reflect bladder neck descent, while a small APVA without a visible anterior base plate edge may reflect hypotonia of the vesical base plate. Transabdominal vesical ultrasonography with the patient in the supine position provides useful information and can be carried out as a routine examination in female patients with micturition disorders.

Ultrasonographic changes of the female bladder neck during development.

BACKGROUND: Our previous study showed that the anteroposterior vesical wall angle (APVA) at the bladder neck on transabdominal ultrasonography varied widely between women. The present study examines whether the APVA changes during development in girls with a normal bladder. METHODS: Seventy-four females aged 0-29 years with normal bladders were examined by transabdominal ultrasonography. They were divided into six age groups and their APVA was measured in the supine position by sagittal ultrasonography. Intravenous urography was conducted to examine bladder neck descent and bladder neck opening. RESULTS: The APVA ranged from 85 to 200 degrees. The mean APVA in girls aged 0-4 years was 129 +/- 30 degrees (+/-SD) and the mean APVA in girls aged 5-9 years was 135 +/- 25 degrees. The mean APVA at ages 10-14 years was 161 +/- 26 degrees; at 15-19 years, 164 +/- 33 degrees; at 20-24 years, 164 +/- 18 degrees; and at 25-29 years, 163 +/- 16 degrees. The APVA values of these four groups were significantly larger (P < 0.05) than those of the two younger groups. No bladder abnormalities were found on intravenous urography. CONCLUSION: The APVA was small in some girls under 10 years of age, but the APVA of girls aged over 10 years was similar to that in young adults. The APVA may reflect bladder base plate tone and be partially related to hormonal changes in females during development.

[Risk factors for duration of urinary incontinence after radical prostatectomy].

PURPOSE: In this study, we examined risk factors for duration of incontinence after radical prostatectomy at our hospital. MATERIALS AND METHODS: From April 1988 to March 2000, 45 patients with prostate cancer underwent retropubic radical prostatectomy at our hospital. Thirty-eight of 45 patients could be followed up. The patients' age, height, weight, body mass index (BMI), preoperative prostatic specific antigen level, clinical stage, nerve-sparing surgery or none, operation time, bleeding volume, resected prostate weight, cancer positive or negative at surgical margins, postoperative stage, radiation therapy or none, anti-androgen therapy or none, duration of postoperative incontinence, and follow-up period were examined. RESULTS: All patients had postoperative stress incontinence, and no one had urge incontinence. Medians of duration of postoperative incontinence and follow-up period were 5.5 and 12 months, respectively. When the patients were divided into 2 groups by the value of each parameter, postoperative anti-androgen therapy (chi 2 test, p = 0.0429) and high BMI (> or = 25.0 kg/m2, p = 0.0206) were related to the long duration (> or = 5.5 months) of postoperative incontinence. CONCLUSION: These results suggest that common factors are involved in the etiology of prolonged incontinence after radical prostatectomy and genuine stress incontinence in women. Therefore, both body weight control and pelvic floor muscle exercise might be also important for the treatment of incontinence after radical prostatectomy.