[PRACTICE AND TRAINING RELATED TO USING ADRENALINE AUTOINJECTORS FOR PARAMEDICS: FACTS AND ISSUES].

BACKGROUND: Although paramedics can use adrenaline autoinjectors (AAIs) during their duties, the actual conditions of their use and the challenges faced remain unclear. We investigated the actual situation and issues pertaining to creating an environment in which paramedics can operate AAIs more effectively. METHODS: A web-based survey was conducted among paramedics who participated in a web-based training session related to their latest knowledge on food allergies and emergency responses in 2022. The survey items included practice and training environments, practices of AAI administration, and regarding AAI administration. RESULTS: Seventy paramedics responded to the survey. Twenty-eight respondents (40%) had experienced cases in which they wished they had an AAI in their work to date, but only one had actually administered one. Thirty-four (49%) indicated that it would be good to have an AAI in the ambulance at all times; 48 (69%) were not concerned about the use of AAI, and the level of concern about its use was significantly related to length of service. The study also revealed that paramedics do not have an adequate training environment regarding AAI. CONCLUSION: Few paramedics have experience in administering AAI, although they are aware of the need for it. For more effective use of AAI, it is necessary to establish a training environment to familiarize paramedics with anaphylaxis and an environment that enables them to use AAI promptly in the field.

Effective alignment method using a diamond notch knife for correlative array tomography.

Correlative array tomography, combining light and electron microscopy via serial sections, plays a crucial role in the three-dimensional ultrastructural visualization and molecular distribution analysis in biological structures. To address the challenges of aligning fluorescence and electron microscopy images and aligning serial sections of irregularly shaped biological specimens, we developed a diamond notch knife, a new tool for puncturing holes using a diamond needle. The diamond needle featured a triangular and right-angled tip, enabling the drilling of deep holes upon insertion into the polished block face. This study describes the application of the diamond notch knife in correlative array tomography.

Antineutrophil Cytoplasmic Autoantibody-negative Pauci-immune Necrotizing Glomerulonephritis with Plasma Cell-rich Tubulointerstitial Nephritis Complicated with Pleuritis and Digital Ischemia.

Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) predominantly affects small vessels. Almost all AAV patients are positive for myeloperoxidase- or proteinase 3-ANCA, and ANCA plays a crucial role in the pathogenesis of AAV. We herein report an ANCA-negative AAV patient with pauci-immune necrotizing glomerulonephritis and plasma cell-rich tubulointerstitial nephritis who was complicated with pleuritis and digital ischemia. ANCA-negative AAV is a rare clinical entity that is difficult to diagnose, and pleuritis and digital ischemia are rare manifestations of AAV. An early diagnosis and appropriate treatment are important, as any delay in the diagnosis may worsen the prognosis.

A Case of Mixed Connective Tissue Disease That Transformed Into Systemic Lupus Erythematosus After a Long Clinical Course.

Mixed connective tissue disease (MCTD), a multisystem autoimmune disease that was first proposed in 1972, has overlapping features with other autoimmune diseases. In recent studies, mixed connective tissue disease has been reported to change into other connective tissue diseases (CTD; such as systemic lupus erythematosus [SLE], polymyositis, and systemic sclerosis [SSc]) in the long term. We report the case of a 58-year-old Japanese man diagnosed with mixed connective tissue disease 15 years ago. During his clinical course, he developed discoid lupus erythematosus, pancytopenia, a low complement titer, proteinuria, and hematuria. He also turned positive for the anti-double-stranded deoxyribonucleic acid (dsDNA) antibody. A kidney biopsy revealed lupus nephritis (LN) class IV. Therefore, we considered this to be a shift from mixed connective tissue disease to systemic lupus erythematosus. We changed his treatment to lupus nephritis, after which he remained in remission. Our case suggests that mixed connective tissue disease may shift to other connective tissue diseases over a long period; therefore, it is necessary to identify whether patients with mixed connective tissue disease fulfill the diagnostic criteria for other connective tissue diseases when new manifestations appear.

A rare case of scleritis and multiple rheumatoid pulmonary nodules associated with seronegative rheumatoid arthritis.

Seronegative rheumatoid arthritis (RA) is less likely to have extra-articular manifestations than seropositive RA. An 80-year-old man with polyarthritis was diagnosed with seronegative RA in which rheumatoid factors and anti-cyclic citrullinated peptides were not detected. He had multiple pulmonary nodules that diminished in size following treatment for RA, leading to the diagnosis of pulmonary rheumatoid nodules. During his treatment course, he developed scleritis, which could have resulted in blindness. As oral steroids did not improve his condition, topical steroid injections were administered, and his symptoms gradually improved. Here, we present a case of seronegative RA with an unusual combination of extra-articular manifestations: rheumatoid pulmonary nodules and scleritis.

Rehabilitation services and related health databases, Japan.

The demographic transition towards an ageing population and the epidemiological transition from communicable to noncommunicable diseases have increased the demand for rehabilitation services globally. The aims of this paper were to describe the integration of rehabilitation into the Japanese health system and to illustrate how health information systems containing real-world data can be used to improve rehabilitation services, especially for the ageing population of Japan. In addition, there is an overview of how evidence-informed rehabilitation policy is guided by the analysis of large Japanese health databases, such as: (i) the National Database of Health Insurance Claims and Specific Health Checkups; (ii) the long-term care insurance comprehensive database; and (iii) the Long-Term Care Information System for Evidence database. Especially since the 1990s, the integration of rehabilitation into the Japanese health system has been driven by the country's ageing population and rehabilitation is today provided widely to an increasing number of older adults. General medical insurance in Japan covers acute and post-acute (or recovery) intensive rehabilitation. Long-term care insurance covers rehabilitation at long-term care institutions and community facilities for older adults with the goal of helping to maintain independence in an ageing population. The analysis of large health databases can be used to improve the management of rehabilitation care services and increase scientific knowledge as well as guide rehabilitation policy and practice. In particular, such analyses could help solve the current challenges of overtreatment and undertreatment by identifying strict criteria for determining who should receive long-term rehabilitation services.

Tant la transition démographique vers un vieillissement de la population que la transition épidémiologique des maladies transmissibles vers les maladies non transmissibles ont entraîné une augmentation de la demande en services de réadaptation dans le monde. Le présent document poursuit plusieurs objectifs: décrire l'intégration de la réadaptation dans le système de santé au Japon, et illustrer comment les systèmes de santé contenant des données réelles peuvent être utilisés en vue d'améliorer de tels services, en particulier pour une population nipponne vieillissante. En outre, il offre un aperçu de la manière dont la politique de réadaptation étayée par des faits s'inspire de l'analyse de vastes bases de données sanitaires japonaises, parmi lesquelles: (i) la base de données nationale des demandes de remboursement au titre de l'assurance-maladie et des bilans de santé spécifiques; (ii) la base de données complète de l'assurance pour les soins longue durée; et enfin, (iii) la base de données du système d'information relatif aux attestations de soins longue durée. Le vieillissement de la population a poussé le Japon à inclure la réadaptation dans son système de santé, surtout depuis les années 1990; aujourd'hui, un nombre croissant de personnes âgées ont aisément accès à des services de réadaptation. Au Japon, l'assurance-maladie globale prend en charge la réadaptation intensive aiguë et post-aiguë (ou de rétablissement). De son côté, l'assurance pour les soins longue durée couvre la réadaptation dans les établissements dédiés et les infrastructures collectives accueillant des personnes âgées, avec pour but de contribuer à préserver l'autonomie au sein d'une population vieillissante. L'analyse de vastes bases de données sanitaires peut favoriser une meilleure gestion des services de réadaptation et accroître les connaissances scientifiques, mais aussi orienter les politiques et pratiques en la matière. Ce type d'analyse peut surtout aider à s'attaquer aux enjeux actuels que représentent les traitements excessifs ou insuffisants, en identifiant des critères stricts permettant de déterminer qui doit faire l'objet d'une réadaptation sur le long terme.

La transición demográfica hacia el envejecimiento de la población y la transición epidemiológica de las enfermedades transmisibles a las no transmisibles han aumentado la demanda de servicios de rehabilitación en todo el mundo. Los objetivos de este artículo son describir la integración de la rehabilitación en el sistema sanitario japonés e ilustrar cómo los sistemas de información sanitaria que contienen datos del mundo real se pueden utilizar para mejorar los servicios de rehabilitación, en especial para la población que envejece en Japón. Además, se ofrece una visión general de cómo la política de rehabilitación fundamentada en la evidencia se guía por el análisis de las grandes bases de datos sanitarias japonesas, como: (i) la Base de Datos Nacional de Reclamaciones al Seguro de Enfermedad y Chequeos Médicos Específicos; (ii) la base de datos integral del seguro de cuidados de larga duración; y (iii) la base de datos del Sistema de Información de Cuidados de Larga Duración para la Evidencia. En particular, desde la década de 1990, la integración de la rehabilitación en el sistema sanitario japonés se ha visto impulsada por el envejecimiento de la población del país y, en la actualidad, la rehabilitación se ofrece de forma generalizada a una cantidad cada vez mayor de adultos mayores. El seguro médico general de Japón cubre la rehabilitación intensiva aguda y posaguda (o de recuperación). El seguro de cuidados de larga duración cubre la rehabilitación en instituciones de larga estancia y centros comunitarios para adultos mayores con el objetivo de ayudar a mantener la independencia en una población que envejece. El análisis de las grandes bases de datos sanitarias puede servir para mejorar la gestión de los servicios de atención a la rehabilitación y aumentar los conocimientos científicos, así como para orientar la política y la práctica de la rehabilitación. En concreto, estos análisis podrían ayudar a resolver los problemas actuales de sobretratamiento y subtratamiento, al identificar criterios estrictos para determinar quién debe recibir servicios de rehabilitación de larga duración.

Dialysis Disequilibrium Syndrome in a Patient With Acute Kidney Injury on Chronic Kidney Disease.

Dialysis disequilibrium syndrome (DDS) is a neurological complication that has been known to occur after hemodialysis (HD). In recent years, the prevalence of DDS has been low as the symptoms are widely recognized; hence, preventive therapies, such as the slow and gentle procedure for HD, are often administered before starting dialysis. However, once DDS occurs, it may cause seizures, coma, and even death in severe cases. Since there has been no established treatment, recognizing risk factors and preventing the syndrome is important. A 76-year-old man was admitted to our hospital due to exacerbation of chronic heart failure. He also had a history of chronic kidney disease and had consulted with his home doctor about the preparation for HD a month before admission. After treatment with diuretics, the symptoms ameliorated, but he experienced presyncope and malaise. Laboratory tests revealed acute anemia and a decrease in renal function. Upper gastrointestinal endoscopy revealed active bleeding from a gastric ulcer, which was successfully stopped. However, his consciousness deteriorated because of uremia; hence, HD was initiated. We used a cellulose triacetate membrane with a surface area of 1.3 m2 and maintained a dialysate flow rate of 500 ml/min with a blood flow rate of 120 ml/min. Four hours after starting HD, he suddenly developed generalized tonic convulsions. The dialysis was immediately stopped, and the patient was transferred to an intensive care unit. A computed tomography scan of the head showed mild edematous change of the brain, and laboratory tests also revealed a rapid decrease of urea nitrogen. We rationalized that he might have developed DDS. After injection of levetiracetam for the treatment of seizures, we initiated continuous hemodiafiltration as renal replacement therapy. Fortunately, his consciousness gradually improved, and he was completely alert on day 18 after admission. With reference to our current report, DDS can occur even following acute kidney injury, as the progression rate of the injury and accumulation of blood urea may not correlate with the risk of the syndrome.

Koshu GRoup Activity, Active Play and Exercise (GRAPE) Study: A Cluster Randomised Controlled Trial Protocol of a School-Based Intervention among Japanese Children.

School-based programmes need to be effective, easy for all, easy to perform within a short duration, and inexpensive. However, no studies have reported whether voluntarily and very short-time active play programmes contribute to improved health outcomes. This study aims to describe the GRoup activity, Active Play and Exercise (GRAPE) cluster randomised controlled trial that examined whether active play interventions of very short durations contribute to increasing physical activity (PA) and bone mass among school-aged children. The trial was conducted in 2018 from January to June, and the activity comprised ≥2 children jumping together for approximately 10 s per session, at least five times a day (approximately 1 min/day). School clusters, pair-matched as per school size (total number of children) and region, were randomly allocated to either intervention or wait-list control groups. The primary outcomes comprised objectively measured changes in PA levels (moderate-to-vigorous PA) evaluated using wrist-worn activity trackers from baseline to the one-year follow-up (six-month post-intervention follow-up) and changes in bone mass evaluated using calcaneus quantitative ultrasound parameters. This study could describe the problems and challenges in school-based PA intervention studies and present findings that could make a potentially important contribution to health education and PA promotion.

The increased frequency of methicillin-resistant Staphylococcus aureus with low MIC of beta-lactam antibiotics isolated from hospitalized patients.

Methicillin-resistant Staphylococcus aureus (MRSA) causes severe infectious diseases and can be life-threatening in healthcare-settings. MRSA is classified into health-care associated (HA)-MRSA strains and community acquired (CA)-MRSA strains based on genotype and phenotype. CA-MRSA has been reported to show the lower minimal inhibitory concentration (MIC) of some antibiotics as compared to HA-MRSA. Recently, the prevalence of CA-MRSA has been increased in worldwide. CA-MRSA is isolated not only from the healthy individuals in a community but also from the patients in healthcare settings. However, the changing trend in frequency of HA-MRSA and CA-MRSA in the hospital setting is not clear. Therefore, we analyzed the trend of MIC to speculate the frequency of HA-MRSA and CA-MRSA in the facility. Moreover, gene mutations were evaluated on resistant gene loci with next generation sequencer. The frequency of strains with low MIC of beta-lactam antibiotics was gradually increased in isolated MRSA strains from the hospitalized patients. Whole genome analysis revealed the frequency of gene mutation was also decreased in some resistant loci, such as blaZ and blaR1. These findings highlight the changing trend of MRSA strains isolated from hospitalized patients.

Detection of Transgenes in Gene Delivery Model Mice by Adenoviral Vector Using ddPCR.

With the rapid progress of genetic engineering and gene therapy, the World Anti-Doping Agency has been alerted to gene doping and prohibited its use in sports. However, there is no standard method available yet for the detection of transgenes delivered by recombinant adenoviral (rAdV) vectors. Here, we aim to develop a detection method for transgenes delivered by rAdV vectors in a mouse model that mimics gene doping. These rAdV vectors containing the mCherry gene was delivered in mice through intravenous injection or local muscular injection. After five days, stool and whole blood samples were collected, and total DNA was extracted. As additional experiments, whole blood was also collected from the mouse tail tip until 15 days from injection of the rAdv vector. Transgene fragments from different DNA samples were analyzed using semi-quantitative PCR (sqPCR), quantitative PCR (qPCR), and droplet digital PCR (ddPCR). In the results, transgene fragments could be directly detected from blood cell fraction DNA, plasma cell-free DNA, and stool DNA by qPCR and ddPCR, depending on specimen type and injection methods. We observed that a combination of blood cell fraction DNA and ddPCR was more sensitive than other combinations used in this model. These results could accelerate the development of detection methods for gene doping.

Action performance in children with autism spectrum disorder at preschool age: a pilot study.

Objectives: Motor deficits related to imitation have been observed in autism spectrum disorder (ASD) patients. This pilot investigation focused on motor performances, including daily tool-use actions, performing an action in the absence of the tool, and imitating (copying tool-use action presented visually), in eight children with ASD and eight children with typical development (TD), with all of pre-school age (4-6 years). Methods: Motor performances were compared between the children with ASD and TD. Differences between an actual tool-use action and performing a tool-use action without the tool according to verbal instruction were also assessed between the groups. Results: Children with ASD showed impairments in imitating, but their actual tool-use actions and tool-use actions without tools following verbal instruction were not different from those of TD children. The spatial error rate in the tasks was higher in children with ASD. Conclusions: The present study indicates that disturbance in imitating actions appears by the age of 4-6 years in children with ASD, possibly as a characteristic symptom affecting motor performance at pre-school age. Generalized apraxia might follow by the age of 8 years or older.

Effects of general anesthesia on postoperative sleep cycles in dentally disabled patients.

AIMS: Although it has been reported that general anesthesia affect the perioperative sleep cycle, no studies have yet evaluated how general anesthesia affects dentally disabled patients. In this study, we investigated the alteration of perioperative sleep cycles in dentally disabled patients receiving dental treatment under general anesthesia. SUBJECTS AND METHODS: The study included 16 patients receiving dental procedures under general anesthesia. Using a sleep monitoring mat, the patients' sleep cycles were measured at home from 5 days before the scheduled surgery date until 5 days after discharge following general anesthesia. The change in all the variables of sleep cycles were analyzed in comparison to the value in preoperative period. Daily differences in these variables were assessed for statistical analysis. RESULTS: The percentage of deep sleep (Stages 3 and 4) decreased significantly on postoperative day 1, and the percentage of light sleep increased. Furthermore, sleep cycles were significantly extended on postoperative day 1. CONCLUSION: The percentage of deep sleep decreased significantly on postoperative day 1 while the percentage of light sleep increased. Sleep cycles were also significantly extended on postoperative day 1. These results reveal that the sleep cycle is somehow affected on the first day following general anesthesia.

The impact of a single-nucleotide mutation of bgl2 on cellulase induction in a Trichoderma reesei mutant.

BACKGROUND: The filamentous fungus Trichoderma reesei (anamorph of Hypocrea jecorina) produces increased cellulase expression when grown on cellulose or its derivatives as a sole carbon source. It has been believed that ß-glucosidases of T. reesei not only metabolize cellobiose but also contribute in the production of inducers of cellulase gene expression by their transglycosylation activity. The cellulase hyper-producing mutant PC-3-7 developed in Japan has enhanced cellulase production ability when cellobiose is used as the inducer. The comparative genomics analysis of PC-3-7 and its parent revealed a single-nucleotide mutation within the bgl2 gene encoding intracellular ß-glucosidase II (BGLII/Cel1a), giving rise to an amino acid substitution in PC-3-7, which could potentially account for the enhanced cellulase expression when these strains are cultivated on cellulose and cellobiose. RESULTS: To analyze the effects of the BGLII mutation in cellulase induction, we constructed both a bgl2 revertant and a disruptant. Enzymatic analysis of the transformant lysates showed that the strain expressing mutant BGLII exhibited weakened cellobiose hydrolytic activity, but produced some transglycosylation products, suggesting that the SNP in bgl2 strongly diminished cellobiase activity, but did not result in complete loss of function of BGLII. The analysis of the recombinant BGLII revealed that transglycosylation products might be oligosaccharides, composed probably of glucose linked ß-1,4, ß-1,3, or a mixture of both. PC-3-7 revertants of bgl2 exhibited reduced expression and inducibility of cellulase during growth on cellulose and cellobiose substrates. Furthermore, the effect of this bgl2 mutation was reproduced in the common strain QM9414 in which the transformants showed cellulase production comparable to that of PC-3-7. CONCLUSION: We conclude that BGLII plays an important role in cellulase induction in T. reesei and that the bgl2 mutation in PC-3-7 brought about enhanced cellulase expression on cellobiose. The results of the investigation using PC-3-7 suggested that other mutation(s) in PC-3-7 could also contribute to cellulase induction. Further investigation is essential to unravel the mechanism responsible for cellulase induction in T. reesei.

Eating tools in hand activate the brain systems for eating action: a transcranial magnetic stimulation study.

There is increasing neuroimaging evidence suggesting that visually presented tools automatically activate the human sensorimotor system coding learned motor actions relevant to the visual stimuli. Such crossmodal activation may reflect a general functional property of the human motor memory and thus can be operating in other, non-limb effector organs, such as the orofacial system involved in eating. In the present study, we predicted that somatosensory signals produced by eating tools in hand covertly activate the neuromuscular systems involved in eating action. In Experiments 1 and 2, we measured motor evoked response (MEP) of the masseter muscle in normal humans to examine the possible impact of tools in hand (chopsticks and scissors) on the neuromuscular systems during the observation of food stimuli. We found that eating tools (chopsticks) enhanced the masseter MEPs more greatly than other tools (scissors) during the visual recognition of food, although this covert change in motor excitability was not detectable at the behavioral level. In Experiment 3, we further observed that chopsticks overall increased MEPs more greatly than scissors and this tool-driven increase of MEPs was greater when participants viewed food stimuli than when they viewed non-food stimuli. A joint analysis of the three experiments confirmed a significant impact of eating tools on the masseter MEPs during food recognition. Taken together, these results suggest that eating tools in hand exert a category-specific impact on the neuromuscular system for eating.

Determination of association constants between 5'-guanosine monophosphate gel and aromatic compounds by capillary electrophoresis.

Hydro gel formed by 5'-guanosine monophosphate (GMP) in the presence of a potassium ion is expected to exhibit interesting selectivity in capillary electrophoretic separations. Here, we estimated the conditional association constants between the hydro gel (G-gel) and aromatic compounds by capillary electrophoresis in order to investigate the separation selectivity that is induced by the G-gel. Several aromatic compounds were separated in a solution containing GMP and potassium ion at different concentrations. The association constants were calculated by correlating the electrophoretic mobilities of the analytes obtained experimentally using a concentration of G-gel. During semi-quantitative estimation, naphthalene derivatives had larger association constants (Kass=10.3-16.8) compared with those of benzene derivatives (Kass=3.91-5.31), which means that the binding sites of G-gel match better to a naphthalene ring than to a benzene ring. A hydrophobic interaction was also found when the association constants for alkyl resorcinol were compared with those of different hydrocarbon chains. The association constants of nucleobases and tryptophan ranged from 6.05 to 12.6, which approximated the intermediate values between benzene and naphthalene derivatives. Consequently, the selective interaction between G-gel and aromatic compounds was classified as one of three types: (1) an intercalation into stacked planar GMP tetramers; (2) a hydrophobic interaction with a long alkyl chain; or, (3) a small contribution of steric hindrance and/or hydrogen bonding with functional groups such as amino and hydroxyl groups.

Biological observation during the daytime of elderly patients with advanced dementia cared for with and without artificial nutrition by percutaneous endoscopic gastrostomy.

AIM: To clarify the activity of demented patients cared for with and without artificial nutrition in a care facility, sequential biological observation was applied using electroencephalograms (EEG), electromyograms (EMG) and electro-oculograms (EOG). METHODS: Awake and sleep patterns and spontaneous swallowing were measured during the daytime in 13 patients with advanced dementia who could orally intake meals (OR patients), and 13 patients with advanced dementia, who received artificial nutrition by percutaneous endoscopic gastrostomy (PEG patients). RESULTS: The awake/sleep pattern fluctuated during daytime in OR and PEG patients, but a fully awake state was relatively preserved around meal times in OR patients. The number of spontaneous swallowing was small in PEG patients (0.1 ± 0.3/h), and the value correlated with the Barthel Index in OR patients. CONCLUSION: Continuous recording of biological activity in demented patients could be informative in providing an overview of their activities. The present results disclosed that meal times were the limited periods keeping OR patients awake consistently, while there was no opportunity for such periods for PEG patients. The number of spontaneous swallowing was especially small in PEG patients, although low Mini-Mental State Examination and Barthel Index scores and poor awake state during daytime were considerable in those patients.

Diabetic mastopathy mimicking breast cancer.

Diabetic mastopathy is a source of diagnostic confusion with breast carcinoma. The association between mastopathy and Type I and II diabetes of long duration has been reported, but this clinical condition is poorly recognized since the clinical, mammographic, and sonographic findings simulate breast cancer. We report a case of diabetic fibrous mastopathy with suspicious clinical and imaging findings in order to draw the attention of physicians to this possibility when encountering similar lesions in the breast of diabetic patients.

Prognostic value of heart rate profiles during cardiopulmonary exercise testing in patients with cardiac disease.

Earlier studies have demonstrated that an impaired capacity to increase heart rate (HR) and a slowed HR recovery following exercise are both associated with cardiovascular mortality. We sought to determine whether HR profiles during exercise testing are superior to respiratory gas parameters in predicting mortality among patients with cardiac disease. Five-hundred and fifty stable cardiac patients (63.4 +/- 9.9 years) underwent a symptom-limited incremental exercise test. Measurements included peak VO(2), VE/VCO(2) slope, HR increase (HR difference from rest to peak exercise), and HR recovery (HR difference from peak to 2 minutes after exercise). Twenty-eight cardiovascular-deaths occurred during 4 years of prospective follow-up. In multivariate analysis, the CPX parameters were found to be significant predictors of cardiovascular-death; peak VO(2) (relative risk (RR), 3.44; 95% CI 1.37 to 8.62; P = 0.008), VE/VCO(2) slope (RR, 1.52; 95% CI 1.11 to 2.08; P = 0.009), while HR increase and HR recovery were determined not to be independent predictors. Although HR profiles during exercise testing are easy to perform and useful as prognostic predictors in patients with cardiac disease, they are not superior to respiratory gas analysis.

Prognostic value of heart rate variability in patients with renal failure on hemodialysis.

BACKGROUND: In patients with renal failure on hemodialysis cardiovascular disease is a major cause of death. It has been reported that diminished heart rate variability (HRV) relates to the unfavorable prognosis in post-infarction and/or heart failure patients. However, the prognostic value of HRV in hemodialysis patients has not been fully established. METHODS AND RESULTS: Time- and frequency-domain analysis of HRV on 24-hour ambulatory electrocardiography recording was assessed prospectively in 383 chronic hemodialysis patients (220 men and 163 women, mean age 57+/-13 years, ejection fraction 65+/-12%). During 2110+/-903 days of follow up, 146 patients died (31 congestive heart failure, 13 fatal myocardial infarction, 13 sudden deaths, 26 stroke, and 63 non-cardiovascular deaths). A Cox univariate analysis identified the following factors as predictors of both all-cause and cardiovascular death: age, gender, ejection fraction, presence of diabetes, and HRV parameters calculated in the time- and frequency-domain. In multivariate analysis, a low standard deviation of all normal RR intervals (SDNN) value was the strongly associated with both all-cause and cardiovascular death (hazard ratios [95% confidence intervals] 0.988 [0.982-0.994] and 0.984 [0.974-0.993], respectively). From Kaplan-Meier survival curves, the incidence of all-cause and cardiovascular death was much greater in patients with a low SDNN (<75 msec), even after adjusting for the presence of diabetes (P<0.0001). CONCLUSIONS: Decreased HRV on 24-hour ambulatory electrocardiography is an independent predictor of mortality in chronic hemodialysis patients.