Recanalization using direct stenting before bowel resection for acute-on-chronic superior mesenteric artery occlusion: A case report.

INTRODUCTION: Acute-on-chronic mesenteric ischemia (ACMI) refers to acute mesenteric ischemia (AMI) developing in a patient displaying typical symptoms of chronic mesenteric ischemia (CMI). Delayed treatment can cause short bowel syndrome and increased mortality. Intervention involves intestinal revascularization and resection of the necrotic intestine. However, the revascularization procedure must consider the chronic nature of the occlusion. PRESENTATION OF CASE: A 79-year-old man presented with periumbilical pain for 6 h. AMI was diagnosed, together with chronic superior mesenteric artery occlusion and suspected intestinal necrosis. The symptomatic CMI might have insufficient blood flow to intestines. Endovascular recanalization of the superior mesenteric artery using direct stenting was performed before laparotomy to improve blood flow to the intestines. Subsequent laparotomy revealed approximately 60 cm of ischemic small bowel extending from the jejunum (300 cm anal to the ligament of Treitz) to the ileum (30 cm oral to the terminal ileum). The necrotic bowel was resected without anastomosis. At the second-look operation, further resection was not required. DISCUSSION: Making a differential diagnosis between acute and acute-on-chronic occlusions is essential for determining the necessity of recanalization and the method of restoring the intestinal blood flow. Here, the patient with symptomatic CMI might have had insufficient blood flow to the intestines despite establishing collateral supply. We determined that recanalization was needed. Direct stenting without predilation could save time to recanalization and result in less risk of distal embolization. CONCLUSION: This case suggests prompt recanalization using direct stenting can minimize subsequent bowel resection in patients with ACMI.

Familial caregivers' experiences with home-visit nursing for persons with dementia who live alone.

AIM: The Japanese Comprehensive Strategy to Accelerate Dementia Measures, known as the New Orange Plan, aims to support people with dementia living in their communities. Home-visit nurses (HVN) are expected to play an important role in this comprehensive support system. In this preliminary study, we explored caregivers' experiences before and after implementation of HVN care for persons with dementia who lived alone. METHODS: This study was a qualitative descriptive design using in-depth interviews with five family caregivers of persons with dementia who lived alone while receiving HVN. Thematic content analysis was undertaken. RESULTS: Before receiving HVN, caregivers experienced anxiety and embarrassment due to the occurrence of dementia symptoms, and they also experienced considerable isolation and anguish after hearing the diagnosis. After initiating HVN, caregivers gained a feeling of security and an alleviation of psychological stress. They also gained a deeper understanding of the disease and appropriate care for dementia patients. Notably, caregivers perceived not only positive changes in themselves, but also in the recipients, such as improvements in symptoms and quality of life. Finally, caregivers realized that people with dementia can live alone if appropriate services are provided. CONCLUSION: HVN can have a positive impact on family caregivers involved in dementia care, as well as on the recipients' psychological status. Overall, the experience of HVN made the family caregivers more positive about home care for their family member with dementia. Although further case studies are needed to make definitive conclusions, we believe that HVN could play a key role in the forthcoming New Orange Plan.

Effect of preceding home-visit nursing on time to discharge in hospitalization for the treatment of behavioural and psychological symptoms of dementia among patients with limited familial care.

BACKGROUND: During hospitalization for behavioural and psychological symptoms of dementia (BPSD), it is imperative to build a support system for each patient in the community for after they obtain symptom remission. To this end, patients lacking adequate family support are less likely to be discharged to their own homes and need stronger support systems to be established. This study therefore investigated the effects of home-visit nursing before admission on time to home discharge among patients with limited familial care who were hospitalized for treatment of BPSD. METHODS: A single-centre chart review study was conducted on consecutive patients admitted from home between April 2013 and September 2015 for treatment of BPSD and who had lived alone or with a working family member. Time to home discharge was compared between patients who had home-visit nursing before their admission and those who did not. RESULTS: In total, 58 patients were enrolled in the study, of whom 12 had preceding home-visit nursing (PHN group) and 46 did not (non-PHN group). Patients in the PHN group were younger (77.7 ± 4.9 vs. 84.1 ± 6.1 years, P = 0.0011) and had higher Mini-Mental State Examination scores (16.8 ± 7.2 vs 11.8 ± 7.3, P = 0.0287). A multivariate Cox proportional hazard regression analysis adjusted for age and Mini-Mental State Examination scores showed a higher likelihood of discharge to home in the PHN group (hazard ratio: 3.85; 95% confidence interval: 1.27-11.6;, P = 0.017) than in the non-PHN group. CONCLUSION: Home-visit nursing before admission of BPSD patients for treatment could improve the rate of discharge to home among patients with limited familial care after subsequent hospitalization. Home-visit nursing could also enhance collaborative relationships between social and hospital-based care systems, and early implementation could improve the likelihood of vulnerable patient types remaining in their own homes for as long as possible.

Effectiveness of dispatcher training in increasing bystander chest compression for out-of-hospital cardiac arrest patients in Japan.

Aim: The Japanese government has developed a standardized training program for emergency call dispatchers to improve their skills in providing oral guidance on chest compression to bystanders who have witnessed out-of-hospital cardiac arrests (OHCAs). This study evaluated the effects of such a training program for emergency call dispatchers in Japan. Methods: The analysis included all consecutive non-traumatic OHCA patients transported to hospital by eight emergency medical services, where the program was implemented as a pilot project. We compared the provision of oral guidance and the incidence of chest compression applications by bystanders in the 1-month period before and after the program. Data collection was undertaken from October 2014 to March 2015. Results: The 532 non-traumatic OHCA cases were used for analysis: these included 249 cases before and 283 after the guidance intervention. Most patients were over 75 years old and were men. After the program, provision of oral guidance to callers slightly increased from 63% of cases to 69% (P = 0.13) and implementation of chest compression on patients by bystanders significantly increased from 40% to 52% (P = 0.01). Appropriate chest compression also increased from 34% to 47% (P = 0.01). In analysis stratified by the provision of oral guidance, increased chest compressions were observed only under oral guidance. Conclusions: We found increased provision of oral guidance by dispatchers and increased appropriate chest compressions by bystanders after the training program for dispatchers had been rolled out. Long-term observation and further data analysis, including patient outcomes, are needed.

Predictors of home discharge among patients hospitalized for behavioural and psychological symptoms of dementia.

BACKGROUND: The Japanese government recently announced the 'Five-Year Plan for Promotion of Measures Against Dementia (Orange Plan)' to promote people with dementia living in their communities. To achieve this, it is imperative that patients hospitalized with behavioural and psychological symptoms of dementia (BPSD) are helped to return to their own homes. The aim of the present study was to identify predictors of home discharge among patients hospitalized for BPSD. METHODS: A single-centre chart review study was conducted on consecutive patients hospitalized from home between April 2006 and March 2011 for the treatment of BPSD. The frequency of discharge back to home was examined in relation to a patient's active behavioural problems and demographics at the time of admission. Diagnoses of dementia were made on the basis of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies. RESULTS: In all, 391 patients were enrolled in the study. Of these patients, 163 (42%) returned home. Multiple logistic regression analysis identified high Mini-Mental State Examination and Nishimura-style senile activities of daily living scores as significant independent predictors of home discharge. In contrast, living alone and manifestation of aggressiveness at the time of admission were negatively associated with home discharge. CONCLUSIONS: Few patients hospitalized for BPSD are discharged home, and this number is affected by a patient's clinical and demographic characteristics at the time of admission. These findings should be considered in designing and implementing optimal management and care strategies for patients with BPSD.

Outcomes of Inpatient Treatment for Behavioral and Psychological Symptoms of Dementia in Alzheimer's Disease Versus Dementia With Lewy Bodies.

OBJECTIVE: Most community-based studies have shown a more malignant clinical course for patients with dementia with Lewy bodies (DLB) than Alzheimer's disease (AD). We examined differences in outcomes between patients with DLB and AD hospitalized for the treatment of behavioral and psychological symptoms of dementia. METHOD: A chart review was conducted of patients with either AD or DLB hospitalized in the acute psychogeriatric ward between January 2008 and December 2011 in Kahoku-City, Ishikawa, Japan. Outcome measures were discharge destinations and time to death. A diagnosis of AD was made according to DSM-5 criteria, whereas a diagnosis of DLB was made according to the Consortium on DLB International Workshop criteria for probable DLB. Pharmacologic treatment was optimized under constant monitoring of patients. Cholinesterase inhibitors and yi-gan san were tried prior to antipsychotics in DLB patients. RESULTS: The study cohort consisted of 224 patients with AD and 106 with DLB. After matching for sociodemographic factors and cognitive and physical function, it was found that antipsychotics were less frequently used during hospitalization in patients with DLB than AD (63% vs 82%, respectively, P < .01), whereas cholinesterase inhibitors (88% vs 43%, P < .001) and yi-gan san (35% vs 20%, P < .05) were more frequently used in patients with DLB. There were no significant differences in discharge destinations between the 2 groups. The 5-year cumulative survival rates were similar in the AD and DLB groups (46.4% vs 45.7%, respectively, P = .6225). CONCLUSIONS: Optimization of pharmacologic treatment during hospitalization could reduce the use of antipsychotics and improve the subsequent clinical course in DLB.

Predictors of time to discharge in patients hospitalized for behavioral and psychological symptoms of dementia.

BACKGROUND/AIMS: In Japan, more than 50,000 patients with dementia are housed in psychiatric facilities, a trend precipitated by prolonged hospitalizations. This study aimed to determine predictors for the time to discharge in patients hospitalized for behavioral and psychological symptoms of dementia (BPSD). METHODS: Medical charts of patients admitted to an acute psychogeriatric ward for treatment of BPSD were reviewed. Cox's proportional hazards model was used to evaluate relationships between active behavioral problems and/or demographics at the time of admission, and the time until favorable discharge (FD), defined as discharge to the patient's own home or a care facility. RESULTS: For the 402 study patients included in this study, median time to FD was 101 days. In addition to family and residential factors, multivariate analysis identified higher Mini-Mental State Examination scores as independent clinical predictors for a shorter hospital stay, whereas male gender and combative behavior as the primary reason for hospital admission were predictors for a longer hospital stay. CONCLUSION: Clinical characteristics can be predictive of the time to discharge for patients with BPSD. Earlier interventions and enhanced care strategies may be needed for patients with a lower likelihood of FD.

Gender differences in clinical manifestations and outcomes among hospitalized patients with behavioral and psychological symptoms of dementia.

OBJECTIVE: To clarify whether hospitalized patients with behavioral and psychological symptoms of dementia (BPSD) show gender differences in manifested symptoms and outcomes. METHOD: A chart review study of patients hospitalized from April 2006 to March 2008 for the treatment of BPSD was conducted. We evaluated the prevalence of symptoms in each of 7 clusters constituting a subscale of the Behavioral Pathology in Alzheimer's Disease Rating Scale and the incidence of favorable discharge, defined as discharge to the patient's own home or care facility. Dementia was diagnosed according to DSM-IV. RESULTS: The study cohort comprised 122 men and 170 women. The men were more likely than the women to present with aggressiveness (78% vs 52%, P < .001) and diurnal rhythm disturbances (89% vs 79%, P < .05) and less likely to present with paranoid, delusional ideation (12% vs 41%, P < .001); hallucination (7% vs 29%, P < .001); affective disturbances (20% vs 40%, P < .001); and anxieties and phobias (15% vs 44%, P < .001). Incidence of favorable discharge was lower in the men (58% vs 77%, P = .001). Even after matching for age, sociodemographic factors, and physical and cognitive functions, the differences in these symptoms persisted, with the exception of diurnal rhythm disturbances. Incidence of favorable discharge was lower in the men (60% vs 77%, P = .0173). CONCLUSION: The data demonstrated gender differences in BPSD and outcomes among hospitalized patients. The findings should be considered when deciding on the optimal management plan for patients with BPSD.

PARP is involved in replicative aging in Neurospora crassa.

Modification of proteins by the addition of poly(ADP-ribose) is carried out by poly(ADP-ribose) polymerases (PARPs). PARPs have been implicated in a wide range of biological processes in eukaryotes, but no universal function has been established. A study of the Aspergillus nidulans PARP ortholog (PrpA) revealed that the protein is essential and involved in DNA repair, reminiscent of findings using mammalian systems. We found that a Neurospora PARP orthologue (NPO) is dispensable for cell survival, DNA repair and epigenetic silencing but that replicative aging of mycelia is accelerated in an npo mutant strain. We propose that PARPs may control aging as proposed for Sirtuins, which also consume NAD+ and function either as mono(ADP-ribose) transferases or protein deacetylases. PARPs may regulate aging by impacting NAD+/NAM availability, thereby influencing Sirtuin activity, or they may function in alternative NAD+-dependent or NAD+-independent aging pathways.

Importance of the domain-domain interface to the catalytic action of the NO synthase reductase domain.

Calmodulin (CaM) activates NO synthase (NOS) by binding to a 20 amino acid interdomain hinge in the presence of Ca (2+), inducing electrons to be transferred from the FAD to the heme of the enzyme via a mobile FMN domain. The activation process is influenced by a number of structural features, including an autoinhibitory loop, the C-terminal tail of the enzyme, and a number of phosphorylation sites. Crystallographic and other recent experimental data imply that the regulatory elements lie within the interface between the FAD- and FMN-binding domains, restricting the movement of the two cofactors with respect to each other. Arg1229 of rat neuronal NOS is a conserved residue in the FAD domain that forms one of only two electrostatic contacts between the domains. Mutation of this residue to Glu reverses its charge and is expected to induce an interdomain repulsion, allowing the importance of the interface and domain-domain motion to be probed. The charge-reversal mutation R1229E has three dramatic effects on catalysis: (i) hydride transfer from NADPH to FAD is activated in the CaM-free enzyme, (ii) FAD to FMN electron transfer is inhibited in both forms, and (iii) electron transfer from FMN to the surrogate acceptor cytochrome c is activated in the CaM-free enzyme. As a result, during steady-state turnover with cytochrome c, calmodulin now deactivates the enzyme and causes cytochrome c-dependent inhibition. Evidently, domain-domain separation is large enough in the mutant to accommodate another protein between the cofactors. The effects of this single charge reversal on three distinct catalytic events illustrate how each is differentially dependent on the enzyme conformation and support a model for catalytic motion in which steps i, ii, and iii occur in the hinged open, closed, and open states, respectively. This model is also likely to apply to related enzymes such as cytochrome P450 reductase.

Impact of depressive mixed state in an emergency psychiatry setting: a marker of bipolar disorder and a possible risk factor for emergency hospitalization.

BACKGROUND: Depressive mixed state (DMX) has been reported to be one of the most useful clinical markers for bipolar II disorder (BP-II) in the outpatient setting. However, the significance of DMX in emergency psychiatry has not been well studied. METHODS: A chart review study of 139 patients who were hospitalized in an emergency psychiatric ward with an initial diagnosis of major depressive disorder (MDD). RESULTS: In 42 (30.2%) patients, the diagnosis was changed to bipolar disorder after a median observation period of 189 days from hospitalization, and of these, 34 were diagnosed as having BP-II. DMX was observed in 56 (40.3%) patients at the time of hospitalization. Compared with patients who remained in MDD, significantly more patients who later developed bipolar disorder had experienced DMX (59.5% vs. 32.0%, p = 0.0044). In multivariate analysis, DMX was one of the independent predictors of conversion to bipolar disorder (OR 2.45, p = 0.037), and the independent predictors for DMX were chronic depression and atypical features (OR 2.85, p = 0.010; OR 3.67, p = 0.046, respectively). In addition, DMX was significantly more frequently observed at emergency hospitalization than at non-emergency hospitalization (48.6% vs. 29.1%, p = 0.0065). LIMITATIONS: A single reviewer evaluated DMX by chart review. CONCLUSION: DMX is a useful marker of bipolar disorder (mainly BP-II) in the emergency psychiatric setting and is closely related to emergency hospitalization for mood disorders. To confirm these findings, a prospective study that systematically evaluates DMX is needed.