A case of upside-down stomach that was effectively treated by postprandial repositioning.

An 88-year-old woman with a history of stomach perforation and lumbar compression fracture was admitted to our hospital with a chief complaint of continuous vomiting, which she had experienced since the previous day. She showed vomiting, spontaneous pain and tenderness from the epigastric fossa through the left flank. In addition, she had marked kyphosis. On a CT scan, although the fornix was located in the abdominal cavity, the antrum and body had escaped into the thoracic cavity. A large volume of gastric content was observed. The patient was diagnosed with upside-down stomach from gastric volvulus and a hiatal hernia. Although we recommended surgery, the patient and her family did not agree with it. Thus, conservative therapy was selected. The patient's symptoms showed a significant improvement after the placement of a nasogastric tube, fasting and fluid therapy. After stabilization, an endoscopic examination was performed. The release of the gastric volvulus was confirmed and the nasogastric tube was removed. We instructed the patient to perform postprandial repositioning, which was based on the running shape of the digestive tract with the goal of achieving the passage of food and preventing a relapse of vomiting. The patient was instructed to first place herself in the right lateral decubitus position and then the prone position after eating. There was no recurrence of vomiting after the patient resumed eating. She was therefore discharged from our hospital. Upside-down stomach is usually an indication for surgery. However, in elderly patients, the fixation of the stomach to the abdominal wall has been reported to occur after endoscopic reduction, and conservative treatment was thus selected in this case.We herein reported a case in which postprandial repositioning was used to treat upside-down stomach.

A case of hereditary hemorrhagic telangiectasia with hepatic encephalopathy due to portal hepatic venous shunt.

An 86-year-old male who was able to perform all activities of daily living (ADL) was diagnosed with hereditary hemorrhagic telangiectasia (HHT) at 70 years of age. Following his diagnosis, he had been receiving treatment at our hospital. After the sudden onset of a consciousness disorder, he was admitted to our hospital's emergency department with asterixis, a high serum ammonia level, and hepatic encephalopathy. After angiography, he was diagnosed with hepatic encephalopathy due to portal hepatic venous shunts. HHT is characterized by abnormal blood vessel construction and the formation of peripheral vasodilatation and shunt blood vessels. Although rare, portal hepatic venous shunts may sometimes cause hepatic encephalopathy. The extent of this shunt increases with age. As Japan is an increasingly aging society, the number of HHT patients with hepatic encephalopathy is likely to increase markedly in the future.

[Long-term care level as a predictor of a poor outcome in elderly patients with pneumonia].

AIM: To determine factors associated with physical decline and a poor prognosis after hospitalization in physically dependent elderly patients with acute pneumonia. METHODS: The subjects included 112 geriatric patients (86.8±5.5 years old) with acute pneumonia consecutively admitted to an inpatient unit of Geriatric Medicine, Kyorin University Hospital in the period from April 2012 to March 2013. All patients were generally treated with broad-spectrum antibiotics according to nursing- and healthcare-associated pneumonia (NHCAP) guidelines. The patients' baseline severity of pneumonia was evaluated according to the A-Drop score and their physical dependency was assessed according to the JABC score before and after admission. RESULTS: The patients were categorized into the community acquired pneumonia group (CAP) (n=29) and NHCAP group (n=83). The patients in the NHCAP group had a longer hospital stay (NHCAP vs. CAP: 33 vs. 21 days, p=0.02), higher A-Drop scores (2.88±0.80 vs. 2.45±0.87 points, p=0.02) and were more frequently diagnosed with aspiration pneumonia (89.2% vs. 42.9%, p<0.0001) than those in the CAP group. Three patients in the CAP group (10.3%) and 13 patients in the NHCAP group (15.7%) died during their hospital stay (p=0.69). Although the rest of the patients were successfully treated for pneumonia, their physical dependency progressed after admission in both groups (p<0.0001). After adjusting for age, gender and the JABC score before admission, NHCAP (risk ratio against CAP: 6.2, 95% CI 1.2-32.2, p=0.03) and a serum albumin lower than 2.5 g/dl (RR: 7.8, 95%CI 1.7-35.7, p<0.01) were significantly associated with the progression of physical dependency after admission. CONCLUSIONS: The diagnosis of NHCAP is a risk factor for the progression of physical dependency. Therefore, palliative care may be an optional approach for frail patients.

[The characteristics of a comprehensive geriatric assessment in patients with mild cognitive impairment with a cerebral white matter lesion].

AIM: Vascular dementia may be referred to as "treatable dementia" because its development and progress can be inhibited by intervention in the early stage. In particular, cerebral white matter lesions are readily encountered the clinical setting. In this study, we aimed to clarify the phenomenon and symptoms of patients with mild cognitive impairment (MCI) with cerebral white matter lesions prior to the onset of dementia. METHODS: The subjects included 181 cases diagnosed with MCI among 643 consecutive new patients of the Center for Comprehensive Care on Memory Disorder at Kyorin University Hospital from January 1, 2013 to January 31, 2014. Patients with particular diseases were excluded. An interview, physical examination, comprehensive geriatric assessment, brain MRI and SPECT were performed for all subjects. The cerebral white matter lesions were evaluated using the modified Fazekas scale. We defined Grades 0 and 1 as the group without apparent cerebral white matter lesions and Grades 2 and 3 as the group with apparent cerebral white matter lesions. We compared the laboratory findings and outcomes of these two groups. RESULTS: The age of the group with apparent cerebral white matter lesions was significantly higher than the group without apparent cerebral white matter lesions (P<0.05). No significant difference was observed regarding gender, MMSE, or "vegetable" term retrieval. A significant difference was observed in the total score and the subordinate component of the 21-item fall risk index and geriatric depression scale between the groups (P<0.05). Additionally, a significant difference was observed regarding the subordinate component of the instrumental ADL, the Dementia Behavior Disturbance Scale and the Zarit Care Burden Scale between the groups (P<0.05). CONCLUSIONS: Our results suggest that the presence of white matter lesions at the stage of MCI has a significant relationship to care burden due to the deterioration of ADL, risk of falling, and the presence of depression and behavior disorders. We speculate that our results are useful for the explanation of the characteristics of MCI with white matter lesion to the patients and the care givers. Furthermore, these results may lead to improvements in the appropriate approach, intervention and appropriate nursing of such patients.

[Examination of cases of pseudogout in succession to inflammatory disease in the elderly].

AIM: Pseudogout is an important causative disease of febrile illness in elderly patients. We experienced cases of pseudogout during or after the progression of inflammatory disease. METHODS: We investigated 14 patients with pseudogout admitted to the Department of Geriatric Medicine at Kyorin University Hospital. Seven patients who developed inflammatory disease prior to the onset of pseudogout are described in greater detail. RESULTS: The affected joint was the knee joint in 12 of 14 cases. Other joints were affected in four cases, and four patients had more than two affected joints in this series. Clear joint cartilage calcification was noted on X-rays in nine of 14 cases, and CPPD crystals were detected in two patients treated with joint puncture. NSAIDs were administered in all cases for treatment. Seven patients had a preceding inflammatory disease, with infectious disease in all cases. Repeat elevation of temperature and inflammatory reactions were seen in seven cases, with progression to bimodal disease in two cases. The average duration of antimicrobial use was 11 days. In three cases, the average duration of antimicrobial use was 33 days, and two or more antimicrobials were used for long-term treatment. CONCLUSIONS: Pseudogout appears as delayed infective disease and fever of unknown origin in the elderly. This condition may easily be overlooked until joint symptoms become apparent. It is extremely important to keep pseudogout in mind as a differential diagnosis of thermogenesis in elderly patients.

Relationship between the severity of cerebral white matter hyperintensities and sympathetic nervous activity in older adults.

AIM: White matter hyperintensities (WMH), visualized on brain magnetic resonance imaging, represent an abnormality related to the development of geriatric syndromes. Recently, it has been found that low sympathetic nervous activity might be associated with physical and cognitive dysfunction in older adults. Therefore, we investigated the relationship between the severity of cerebral WMH and sympathetic nervous activity, measured by the heart rate variability. METHODS: We carried out a cross-sectional study of 39 older patients. Holter recording was carried out for 30 min. From the RR intervals on the electrocardiogram, the standard deviation of the normal-to-normal intervals, the standard deviation of all normal-to-normal intervals in all the five segments of the entire recording, low frequency (LF), high frequency (HF) and LF/HF were calculated. In regard to the WMH, periventricular hyperintensities and deep white matter hyperintensities (DWMH) were rated according to the Fazekas classification. The WMH were also rated semiquantitatively according to the methods developed by Junque (periventricular hyperintensities) and de Groot (DWMH). RESULTS: The LF/HF showed significant negative correlations with the total and regional periventricular hyperintensities, as well as DWMH. Multiple regression analysis showed that the negative associations remained significant between the LF/HF and DWMH (total, temporal, occipital). Furthermore, fall risk index significantly correlated with the LF/HF, total and the occipital DWMH. CONCLUSIONS: The severity of the DWMH was associated with the LF/HF and the fall risk, one of the important geriatric syndromes, suggesting that WMH, sympathetic nervous dysfunction and geriatric syndrome are interrelated to each other. Geriatr Gerontol Int 2018; 18: 569-575.

Efficacy of combined use of three non-invasive atherosclerosis tests to predict vascular events in the elderly; carotid intima-media thickness, flow-mediated dilation of brachial artery and pulse wave velocity.

BACKGROUND: Intima-media thickness (IMT) of the carotid artery, flow-mediated dilation (FMD) of the brachial artery, and pulse wave velocity of the central artery (PWV) have been widely used to evaluate progression of atherosclerosis. Our previous work has revealed that IMT, FMD and PWV are related to each other, and the combination of these measurements was useful in identifying patients with atherosclerotic disease. The aim of the present study was to investigate whether combination of these measurements would predict future cardiovascular events better than each test alone. METHODS AND RESULTS: From November 2000 to March 2008, 274 consecutive elderly subjects (men/women; 114/160, mean age; 71 ± 12 years) were enrolled in this study. We measured IMT, FMD, and PWV in all of these subjects and followed them for a mean of 41 ± 28 months. During the follow-up period, vascular events occurred in 42 patients (15.3%). IMT (hazard ratio = 1.28 [95%CI, 1.09-1.50], p = 0.002 per 0.1 mm increase in mean IMT) and brachial-ankle (ba) PWV (hazard ratio = 1.06 [95%CI, 1.01-1.10], p = 0.015 per 1 m/s increase in baPWV) were independent predictors of future vascular events by Cox proportional hazard analysis, although FMD did not reach statistical significance (hazard ratio = 0.85 [95%CI, 0.72-1.01], p = 0.062 per 1% increase in %FMD). Importantly, the number of tests showing results in the worst tertile was a more powerful predictor (hazard ratio = 2.21 [95%CI, 1.42-3.43], p = 0.0004 for number of tests showing worst tertile) of future vascular events than either IMT, baPWV, or FMD alone. When both IMT and baPWV (with respective cut-off values of 0.98 mm and 19.1 m/s) were taken into consideration, the efficacy increased as compared with each test alone (odds ratio 4.9). CONCLUSION: These results indicate that IMT and baPWV, especially when combined, are useful in predicting future vascular events in elderly subjects.