Association of the Number of Teeth With Physical Function and Length of Hospital Stay After Hip Fracture Surgery: A Prospective Observational Study at a Tertiary Hospital in Japan.

OBJECTIVES: Although lower-extremity muscle strength is associated with physical function, there are challenges in assessing the muscle strength of patients after hip surgery due to pain or limited cognitive function. The number of teeth is a characteristic that can be easily examined. Although the relationship between the number of teeth and physical function has been reported in recent years, there are no reports examining the relationship with prognosis in patients with hip fractures. Therefore, this study aimed to investigate the relationship between the number of teeth and physical function and length of hospital stay after hip fracture surgery and to evaluate the predictive efficacy of the number of teeth on postoperative prognosis. METHODS: This prospective cohort study was conducted in a tertiary clinical care facility. Patients aged ≥65 years who underwent hip surgery were included. A total of 101 patients (mean age: 85.1±8.0 years) were included. The factor analyzed was the number of teeth at admission. Patients were divided into two groups according to the number of teeth: those with ≥20 and those with ≤19 teeth. The outcomes were knee extension muscle strength-to-weight ratio at two weeks postoperatively and the length of hospital stay. A multiple regression analysis was performed to determine the association between the two groups. RESULTS: Of 101 patients, 79 (78.2%) had ≤19 teeth, whereas 22 (21.8%) had ≥20 teeth. The mean muscle strength-to-weight ratio and length of hospital stay were 0.26±0.11 kgf/kg and 57.5±31.4 days, respectively. Multiple regression analysis revealed that the number of teeth was significantly associated with the muscle strength-to-weight ratio (ß=-0.26, p=0.04) but not with the duration of hospitalization (ß=0.17, p=0.09). CONCLUSIONS: We suggest that assessment of the number of teeth at admission may be a useful predictor of patient physical function.

Pregnancy and delivery in women receiving maintenance hemodialysis in Japan: analysis of potential risk factors for neonatal and maternal complications.

INTRODUCTION: Average dialysis vintage in Japan is among the longest in the world, providing a unique opportunity to characterize pregnancy under conditions of long dialysis vintage. In 2017, we carried out a nationwide survey following up on a similar survey in 1996, in which we investigated the prevalence and outcomes of pregnancy in women undergoing dialysis and assessed risk factors associated with neonatal and maternal complications. METHODS: The target population was women aged 15-44 years undergoing maintenance dialysis between 2012 and 2016. The survey was conducted in 2693 dialysis units. RESULTS: A response was obtained from 951 dialysis units, yielding a target population of 1992 women of childbearing age receiving hemodialysis or peritoneal dialysis. Pregnancy occurred only among women receiving hemodialysis, with 25 pregnancies (1.26% in 5 years) being reported for 20 women. Detailed information about 19 pregnancies (mean age 34.6 ± 5.7 years at conception, mean dialysis vintage 8.4 ± 7.3 years) indicated 4 spontaneous abortions, 1 elective abortion, no neonatal deaths, and 14 surviving infants, including 5 full-term (≥ 37 weeks at birth), 2 late preterm (34-36), and 3 extremely preterm (< 28) cases. Neonatal complications occurred in the offspring of 3 mothers who had end-stage renal disease (ESRD) caused by primary glomerulonephritis and serum albumin levels (sAlb) ≤ 3.2 mg/dL in the first trimester. These mothers had started dialysis at 12, 17, and 30 years of age. ESRD caused by diabetic nephropathy or primary glomerulonephritis, age at conception ≥ 38 years, and sAlb ≤ 3.2 mg/dL were associated with maternal complications, although not significantly. CONCLUSIONS: In this study, the pregnancy rate of Japanese women with ESRD was 0.25% per year. The study generates the hypothesis that ESRD caused by diabetic nephropathy and age at conception ≥ 38 years are potential risk factors for maternal complications but not for neonatal complications in dialysis patients, and that hypoalbuminemia is a potential risk factor for both kinds of complications.

[Perioperative Effect of Intraoperative Fluid Restriction with the Same Fixed Volume of 5 ml · kg(-1) · h(-1) in Patients Undergoing Major Abdominal Versus Thoracic Surgery].

BACKGROUND: Major abdominal surgery accompanies the higher magnitude of physiological stress response and may require an additional replacement fluid for the redistributed volume. Intraoperative volume restriction strategy is recommended to avoid fluid overload leading to increased mortality. We conducted a comparative study of the perioperative effects of intraoperative fluid restriction in abdominal versus thoracic surgery. METHODS: Each 15 patients having major abdominal or thoracic surgery were studied prospectively. All participants were identically given intraoperative iv crystalloid of 5 ml · kg(-1) · hr(-1) under combined epidural/general anesthesia. Plasma level of AVP, aldosterone, angiotensin II and IL-6 as well as body water composition by bioelectrical impedance analysis was examined at preoperative period, at the end of surgery and on the first postoperative day. RESULTS: In abdominal surgery group there was significantly less intraoperative urine output compared with thoracic surgery group. No significant differences were found between two groups in extracellular water volume chnages, AVP, aldosterone angiotensin II, IL-6 level and postoperative renal function. CONCLUSIONS: Restrictive fluid therapy with intraoperative crystalloid of 5 ml · kg(-1) · hr(-1) can be safely used with no serious adverse events in abdominal surgery. In conclusion we had better not make any traditional difference in intraoperative fluid management between abdominal and thoracic surgery even if their stress response differs in magnitude.

[Efficacy and safety of remifentanil-based regimen for postoperative pain management in abdominal surgery patients: a double-blind study with low-dose remifentanil infusion of 0.02 microg x kg(-1) x min(-1)].

BACKGROUND: Remifentanil is a powerful analgesic with fast onset and ultra-short duration of action. Its context-sensitive half-time is consistently short even after a prolonged infusion. Remifentanil is effective for providing better postoperative analgesia, but this method is not generally accepted in Japan. The present study was conducted to document efficacy and safety of low-dose remifentanil infusion in postoperative patients. METHODS: Forty patients undergoing abdominal surgery were studied prospectively. They were randomly assigned to either remifentanil (0.02 microg x kg(-1) x min(-1)) or placebo group. Postoperatively all patients received continuous epidural anesthesia with lidocaine and IV patient-controlled analgesia with fentanyl. Flurbiprofen was administered only when no pain relief was achieved. Visual analogue scale (VAS), requirement of fentanyl and flurbiprofen, and the incidence of remifentanil-related adverse effects (respiratory depression, nausea, vomiting, pruritus) were examined at 3 hourly intervals for 12 hours. RESULTS: There are no statistical differences between two groups in pain scores. No adverse events including respiratory depression occurred throughout the study in both groups. CONCLUSIONS: Remifentanil infusion at 0.02 microg x kg(-1) x min(-1) can safely be used without any serious adverse events, while it may not be enough for postoperative analgesia. The best dosage of this drug for postoperative analgesia remains to be elucidated.

[Postoperative pain management in video-assisted thoracic surgery using a continuous unilateral intercostal analgesia].

BACKGROUND: Optimal pain management after video-assisted thoracic surgery (VATS) remains an open issue. We prospectively studied the analgesic effect of intercostal analgegia (ICA) by comparison with epidural analgesia. METHODS: Twenty-two patients undergoing VATS procedures were randomly divided into ICA (n = 8) or epidural (n = 14) group. Postoperatively 2 ml x hr(-1) of 0.2% ropivacaine was delivered continuously through intercostal or epidural catheter. Moreover, each group received the equal dose of fentanyl (0.25 x µg(-1). kg(-1) x hr(-1)) intravenously or epidurally. When no pain relief was achieved, iv fentanyl was given as a rescue. Requirement of additional fentanyl and pain score using a visual analogue scale (VAS) were documented for 19 hours. RESULTS: The mean pain scores at rest, mobilization and with coghing were slightly higher in the ICA group. Total additional dose of iv fentanyl was significantly different between the groups (ICA 147 ± 41 vs Epidural 39 ± 15 µg; P = 0.015). Pain scores and fentanyl requirements spread over the lower range. The mean of VAS in ICA group was less than 5 even at coughing, suggesting clinically irrelevant. CONCLUSIONS: In patients with coagulopathy, multimodal approach using intercostal analgesia supplemented by intravenous patient-controlled analgesia may be an alternative to epidural analgesia for postoperative pain management.

[Intraperitoneal irrigation for pseudomyxoma peritonei-a case of critical metabolic alkalosis precipitated by irrigation with 101 of sodium bicarbonate--].

Pseudomyxoma peritonei causes marked accumulation of jelly-like ascites in the peritoneal cavity. Removal of much mucinous ascites by irrigating the cavity appears to be an effective treatment. We describe a patient who underwent the irrigation with sodium bicarbonate solution and developed critical alkalemia. A 68-year-old woman with normal renal function was operated on for recurrent pseudomyxoma peritonei. Fol- lowing the excision of primary lesion, her intraperitoneal cavity was irrigated with 10 1 of 7% sodium bicarbonate in about 45 minutes. Thirty minutes after irrigation, blood gas analysis revealed severe metabolic alkalosis (pH 7.714, BE 25.6 mmol x l-1 ) with electrolyte disorder (Na 157.8 mmol x l-1 K 2.31mmol x l-1, Ca 0.73 mmol x l-1). Hypotension (<60 mmHg) and sinus tachycardia (>130 beats x min -1) supervened 75 minutes later. Transferring to the ICU, she was given KC1 solution intravenously based on serial blood analysis while on mechanical ventilation. The next day acid-base disturbance returned spontaneously to normal (pH 7.45, BE 8.0mmol x l-1), leading to endotracheal extubation. Electrolyte imbalance was gradually resolved on 2nd POD and she was discharged from the ICU. Intraperitoneal irrigation with sodium bicarbonate requires special perioperative considerations for lifethreatening alkalemia, especially in a patient with renal impairment.

[The evaluation of total body water composition during caesarean section under spinal anesthesia].

BACKGROUND: Hypotension is a common adverse effect of spinal anesthesia (SA). Preoperative fluid infusion is recommended to prevent hypotension during caesarean section. The aim of this study is to document relationship between preoperative total body water (TBW) and the amount of the vasopressors given intraoperatively and to evaluate the change of maternal body water composition (BWC). METHODS: In 57 patients scheduled for caesarean section under SA, maternal BWC was measured by bioelectrical impedance analysis method. SA was performed using 0.5% isobaric bupivacaine 2 ml and fentanyl 20 microg at L3-4 intervertebral space. After this procedure, the impedance was measured again. We investigated the correlation between TBW and the amount of the vasopressor and the change of maternal BWC before and after SA. RESULTS: No positive linear correlation existed between the preoperative TBW and the amount of vasopressors given intraoperatively. SA produced a 3.8% increase in TBW and a 4.7% increase in extracellular water (ECW, P < 0.01). CONCLUSIONS: Preoperative TBW does not affect the amount of vasopressors given during caesarean section, which suggested massive fluid infusion can not always prevent hypotension after SA. A slight changes in TBW and ECW may be induced by SA, while the exact physiological and clinical significance of these observation remains to be elucidated.

CT findings of spontaneous intraperitoneal rupture of the urinary bladder: two case reports.

We report two cases of spontaneous bladder rupture. Preoperative diagnosis was difficult and the correct diagnosis was made at surgery. Reviewing the initial abdominopelvic CT of our second patient, the bladder wall defect and blood attenuation near the bladder were observed. These findings were consistent with the operative findings, and would have led to correct preoperative diagnosis if we had had sufficient knowledge of spontaneous bladder rupture. Under urinary catheterization, ascites and free intraperitoneal air were identified in both patients. These findings were indistinguishable from those for bowel perforation, which was our preoperative diagnosis. Significant changes in ascites volume between pre and post urinary catheterization can be an indication of spontaneous bladder rupture.

Computed tomography findings of spontaneous perforation of pyometra.

We report herein a case of spontaneous perforation of pyometra leading to diffuse peritonitis. This pathological condition is rare, and preoperative diagnosis is difficult. We were able to make the correct diagnosis preoperatively using contrast-enhanced abdominopelvic computed tomography. Both intrauterine and extrauterine fluid collections and defects of the uterine fundus were key findings, and reconstructed sagittal and coronal images were useful. In elderly female patients presenting with acute abdomen, ruptured pyometra should be considered as a possibility.

Gallbladder hernia into the foramen of Winslow: CT findings.

We present a case of gallbladder hernia into the foramen of Winslow. During the diagnosis of hernia, ultrasonography, computed tomography and intravenous computed tomography, cholangiography of the abdomen were performed. Ultrasonography detected gallstone, but did not provide sufficient information to diagnose gallbladder hernia. Computed tomography yielded the correct diagnosis. At laparoscopic cholecystectomy, the diagnosis was confirmed.

Electrophysiological and pharmacological characterization of the K(ATP) channel involved in the K+-current responses to FSH and adenosine in the follicular cells of Xenopus oocyte.

The follicular cells surrounding Xenopus oocyte under voltage clamp produce K(+)-current responses to follicle-stimulating hormone (FSH), adenosine (Ade), and intracellularly applied cAMP. We previously reported that these responses are suppressed by the stimulation of P2Y receptor through phosphorylation by PKC presumably of the ATP-sensitive K(+) (K(ATP)) channel. This channel comprises sulfonylurea receptors (SURs) and K(+) ionophores (Kirs) having differential sensitivities to K(+) channel openers (KCOs) depending on the SURs. To characterize the K(+) channels involved in the FSH- and Ade-induced responses, we investigated the effects of various KCOs and SUR blockers on the agonist-induced responses. The applications of PCO400, cromakalim (Cro), and pinacidil, but not diazoxide, produced K(+)-current responses similar to the FSH- and Ade-induced responses in the magnitude order of PCO400 > Cro >> pinacidil in favor of SUR2A. The application of glibenclamide, phentolamine, and tolbutamide suppressed all the K(+)-current responses to FSH, Ade, cAMP, and KCOs. Furthermore, both the FSH- and Ade-induced responses were markedly augmented during the KCO-induced responses, or vice versa. The I-V curves for the K(+)-current responses induced by Cro, Ade, and FSH showed outward rectification in normal [K(+)](o), but weak inward rectification in 122 mM [K(+)](o). Also, stimulations of P2Y receptor by UTP or PKC by PDBu markedly depressed the K(+)-current response to KCOs in favor of Kir6.1, as previously observed with the responses to FSH and Ade. These results suggest that the K(+)-current responses to FSH and Ade may be produced by the opening of a novel type of K(ATP) channel comprising SUR2A and Kir6.1.

Malignant triton tumor in a patient with neurofibromatosis type 1.

We report a case of neurofibromatosis type 1 (NF1) complicated by a malignant triton tumor (MTT), with an emphasis on B-mode sonographic (US) and contrast-enhanced US (CEUS) findings. To the best of our knowledge, this is the first report describing CEUS findings of MTT. The mass was poorly demarcated and composed of an internal echogenic area and an outer hypoechoic zone. CEUS findings showed the outer zone to be strongly enhanced, and the internal area was very poor in blood flow because of necrotic tissues.

Rupture of liver metastasis: report of a case with an emphasis on contrast-enhanced US.

We present a case of liver metastasis from an uterine leiomyosarcoma in which contrast-enhanced ultrasonography (CEUS) helped determine the bleeding point and prevented a delay in devising diagnostic and therapeutic strategies. CEUS allowed us to differentiate active from nonactive bleeding on the basis of presence or absence of contrast extravasation in the ascites. CEUS is the first examination performed when liver tumor rupture is suspected. Reference to the preangiographic CEUS results is expected to provide a road map for angiography.

[Long-term suppressive effect of falecalcitriol on parathyroid hormone secretion in secondary hyperparathyroidism in hemodialysis patients].

Alfacarcidol and calcitriol are widely used to treat secondary hyperparathyroidism associated with chronic renal failure, but it is often not possible to administer doses high enough to sufficiently inhibit parathyroid hormones because of the risk of hypercalcemia and hyperphosphatemia. We administered falecalcitriol (Hornel) Tablets) to patients with poorly controlled secondary hyperparathyroidism. The usefulness of falecalcitriol was demonstrated by the fact that control of intact-PTH was maintained for up to 24 months without a clear increase in serum Ca x serum inorganic phosphorus (iP), iP, and ALP levels.

[Levels of serum ascorbate and its metabolites in hemodialysis patients].

The status of ascorbic acid (AA) in dialysis patients is the subject of debate. Some reports have found AA to be deficient in dialysis patients, while others have found that AA is not deficient. In an attempt to confirm AA serum concentrations in dialysis patients, we analyzed the concentrations of AA as well as its metabolites using the specific determination of AA with chemical derivatization and the HPLC method. We studied 131 patients under maintenance hemodialysis therapy (HD), 23 patients with chronic renal failure (CRF) and 48 healthy controls (C). Serum concentrations of AA and the AA metabolites dehydroascorbic acid (DHA) and 2, 3-diketogulonate (DKG) were measured by HPLC. Nine HD patients were taking AA supplements. Seventy-six (62.3%) of the 122 HD patients not taking AA supplements exhibited deficient levels of AA (< 20 microM), while 13 (56.5%) of the 23 CRF patients and 9 (18.8%) of the 48 C showed deficient levels of AA. Analysis of AA metabolites in the normal-range AA (20-80 microM) group revealed that the DHA/AA ratio in HD patients was significantly higher than in C (3.3 +/- 2.6% and 1.2 +/- 2.2%, respectively). The DKG/AA ratio in HD patients was higher than in CRF patients (3.6 +/- 5.2% vs. 0.9 +/- 1.9%), whereas DKG was not detected in C. When compared to serum levels before the start of dialysis, serum AA, DHA and DKG concentrations at the end of the dialysis session decreased by an average of 74.2, 84.0 and 78.8% respectively. In HD patients, serum levels of thiobarbituric reactive substances (TBARS) were significantly lower in the higher AA (> 80 microM) group than in the deficient and normal-range AA groups. In 12 AA-deficient patients, after 1 month of taking AA supplements (200 mg/day), serum AA levels rose to 79.9 microM, while serum TBARS level declined when compared with levels before supplementation. In conclusion, the frequency of AA deficiency in dialysis patients is extremely high. AA deficiency in HD patients may result in high TBARS levels, which reflect increased oxidative stress. Adequate AA supplementation should therefore be considered in such patients.

Changes in rat lens proteins and glutathione reductase activity with advancing age.

We examined the changes in the amounts of water-soluble and water-insoluble proteins of rat lenses, and in glutathione reductase activity and glutathione reductase gene expression, with advancing age. The lens total protein increased in 1-month-old rats, 3-month-old rats, and 6-month-old rats, but thereafter decreased in 12-month-old-rats. The water-soluble proteins decreased with advancing age, while the water-insoluble proteins increased. The glutathione reductase activity decreased with advancing age, but the decreased glutathione reductase activity almost recovered by addition of flavin adenine dinucleotide (FAD) in vitro. However, advancing age had no effect on the level of mRNA for glutathione reductase.