Graduate School of Health Care Sciences, Jikei Institute

本研究は、高齢患者が入院中に転倒・転落する可能性を、看護師がどのように認識しているかを明らかにすることを目的とした。A病院の高齢入院患者162名のアセスメントを担当した看護師60名を対象に、転倒・転落リスクアセスメントに関する自記式質問紙調査を実施した。重回帰分析の結果、転倒・転落リスクアセスメント結果の捉え方とアセスメントの正確さの自己評価が、高齢患者の入院中の転倒・転落リスクに関する看護師の認識と関連することが示された。

Patient: Female, 46-year-oldFinal Diagnosis: Median arcuate ligament syndromeSymptoms: Abdominal and/or epigastric painClinical Procedure: —Specialty: Gastroenterology and Hepatology • SurgeryObjective:Rare diseaseBackground:Median arcuate ligament syndrome (MALS) poses a considerable challenge in terms of diagnosis due to its manifestation of diverse symptoms linked to constriction of the median arcuate ligament surrounding the celiac artery. The present study introduces an earlier diagnostic modality using ultrasound measurements of the flow velocity of the celiac artery during the inspiratory and expiratory phases, with the latter being higher than the former, to avoid prolonged follow-up of postprandial symptomatology.Case Report:A 46-year-old female patient presented with acute postprandial abdominal pain, which was alleviated by analgesic medication. The findings from the physical examination and laboratory tests were within normal limits. Further investigations were conducted due to persistent symptoms, revealing an elevation in celiac artery flow velocity during expiration on ultrasound. The diagnosis of median arcuate ligament syndrome (MALS) was confirmed through contrast-enhanced CT and angiography. Subsequently, the patient underwent laparoscopic release of the median arcuate ligament, leading to alleviation of symptoms at the 1-year follow-up assessment.Conclusions:Our case report highlights the importance of a dynamic imaging diagnostic strategy for MALS. When encountering challenging postprandial abdominal pain that is hard to diagnose, it could be crucial to utilize abdominal ultrasound to measure the flow velocity of the celiac artery. This approach may serve as a valuable screening method for identifying MALS and, subsequently, prompt the need for further diagnostic tests.

To holistically evaluate neurodevelopmental outcomes and quality of life (QOL) of Japanese patients with biliary atresia (BA) and to investigate the factors associated with the outcomes. This study enrolled patients with BA aged 5-18 years who visited Osaka University Hospital in 2021. Neurodevelopmental assessments were performed to evaluate intellectual ability, cognitive functions and adaptive skill levels. Furthermore, emotional and behavioral issues, characteristics of attention deficit hyperactivity disorder, and QOL were concomitantly assessed in the same cohort. Biochemical and social factors associated with the results were examined. Fifty-three patients, with a median age of 11.2 years were included in the analyses. Patients with BA had a significantly lower Full-Scale Intelligence Quotient or developmental quotient (FSIQ/DQ) score and Vineland Adaptive Behavior Scale (VABS) composite score than the general Japanese population. Household education level and short stature were associated with low and borderline FSIQ/DQ and VABS composite scores, respectively. Among patients with low and borderline FSIQ/DQ scores, those with average or high VABS composite scores received significantly less neuroeducational care than those with low and borderline VABS composite scores. Despite the low FSIQ/DQ and VABS composite scores, the total QOL scores were higher than those of the general population. Patients with BA had intellectual and behavioral impairments. Notably, patients with intellectual impairments are overlooked and not followed up, especially if adaptive skills are maintained.

As the population ages in Japan and worldwide, the number of informal caregivers, such as family members, providing nursing care to older individuals is increasing. Among caregiving tasks, repositioning care, which causes lower back pain, is frequent and burdensome for caregivers. Therefore, we developed a position-changing device that can adjust and support the care recipient’s body in the lateral position. This was a feasibility study of the device-assisted care provided by non-professionals using the device we developed. Of the 40 healthy volunteers enrolled, 17 simulated caregivers and 17 simulated care recipients finally participated in the study. One caregiver and one care recipient were paired to engage in two types of care: device-assisted care and manual care. Furthermore, the care provided by the caregiver and received by the care recipient were evaluated. Non-professionals were able to use the device successfully and safely after a short period of practice, and both caregivers and care recipients rated the device-assisted care positively. The study results suggest that informal caregivers can also provide safe and comfortable care that is less burdensome than manual care by using a caregiver-assistive device.

Abstract Background and Aims The malnutrition is often prevalent in hemodialysis (HD) patients, and the risk of mortality is strongly correlated with malnutrition. We assume the dynamic change and trend of albumin in HD patients are mortality essential, however there is not enough information on these data. The aim of this study was to investigate the association of long-term prognosis and decrease rate of albumin for one-year. Method We enrolled HD patients in six centers to a retrospective follow-up study. All patients had received HD from January 2014 to December 2014 and serum albumin data were collected every month in this period. We defined decrease rate in serum albumin as (average of albumin value for the year - decrease value for the year) / average of albumin value for the year. We categorized these patients into two groups according to the median value of the decrease rate. Then these patients were observed for three years. The primary and secondary outcome of this study was all-cause mortality and the combined endpoint of mortality and major cardio-cerebrovascular adverse events (MACCE). To evaluate cut-off value in decrease rate of serum albumin, Receiver Operating Characteristic (ROC) curve analysis was performed. Moreover, restricted cubic splines were used to detect the possible nonlinear dependency of the relationship between decrease rate in serum albumin and mortality. Results Six-hundred twenty-one HD patients were enrolled into this study. The median rate of decrease in albumin in the enrolled patients was 7.5%. Compared to the low decrease fluctuation group(n = 321), the high decrease fluctuation group (n = 300) was significantly older (67 vs 66 years; p = 0.03), more frequently had diabetes mellitus (51.7 vs 39.3%; p = 0.02), had lower serum creatinine (9.34 vs 10.69 mg/dl; p <0.001) and lower body mass index (20.3 vs 21.3; p = 0.01). The mean follow-up period was 31.0±10.1 months. During the follow-up period, there were 121 cases (19.5%) in all cause death and 191 cases (30.5%) in combined endpoint, respectively. Kaplan-Meier analysis showed that high decrease fluctuation in serum albumin group had a significantly worse prognosis in both all-cause mortality (Log-rank, p = 0.01) and combined endpoint (Log-rank, p = 0.002) than low decrease fluctuation group (Figure 1). Multi-variate Cox proportional hazard model revealed that high decrease fluctuation in serum albumin was a significantly associated with a higher risk of all-cause mortality and combined endpoint (hazard ratio 1.47 (95%CI: 1.02-2.13), p = 0.03, hazard ratio 1.49 (95%CI:1.11-1.99), p = 0.007). The cut-off value for all-cause mortality in decrease rate of serum albumin was 8.4% by ROC curve analysis. Moreover, through multivariable restricted cubic spline regression, continuous variation in decrease rate in serum albumin was found to be related to all-cause mortality in a nonlinear manner (Figure 2). Conclusion In HD patients, high decrease fluctuation in serum albumin was significantly associated with an increased risk of all-cause mortality compared low decrease fluctuation in serum albumin. Our findings suggest that regarding serum albumin, we might need to pay attention not only to its monthly value, but also to its decreasing fluctuation.

Columnar structure is one of the most fundamental morphological features of the cerebral cortex and is thought to be the basis of information processing in higher animals. Yet, how such a topographically precise structure is formed is largely unknown. Formation of columnar projection of layer 4 (L4) axons is preceded by thalamocortical formation, in which type 1 cannabinoid receptors (CB1R) play an important role in shaping barrel-specific targeted projection by operating spike timing-dependent plasticity during development (Itami etal., J. Neurosci. 36, 7039-7054 [2016]; Kimura & Itami, J. Neurosci. 39, 3784-3791 [2019]). Right after the formation of thalamocortical projections, CB1Rs start to function at L4 axon terminals (Itami & Kimura, J. Neurosci. 32, 15000-15011 [2012]), which coincides with the timing of columnar shaping of L4 axons. Here, we show that the endocannabinoid 2-arachidonoylglycerol (2-AG) plays a crucial role in columnar shaping. We found that L4 axon projections were less organized until P12 and then became columnar after CB1Rs became functional. By contrast, the columnar organization of L4 axons was collapsed in mice genetically lacking diacylglycerol lipase α, the major enzyme for 2-AG synthesis. Intraperitoneally administered CB1R agonists shortened axon length, whereas knockout of CB1R in L4 neurons impaired columnar projection of their axons. Our results suggest that endocannabinoid signaling is crucial for shaping columnar axonal projection in the cerebral cortex.

Patients with pruritus receiving hemodialysis frequently experience oppressive physical and psychiatric symptoms that directly affect their quality of life and increase mortality. However, treatment options are limited. To determine the clinically recommended dose of difelikefalin, a κ-opioid receptor agonist, based on the efficacy, dose response, safety, and pharmacokinetics. This randomized, double-blind, placebo-controlled, 4-arm phase 2 trial was conducted from February 1, 2019, to October 22, 2019, at 94 sites in Japan. Patients with moderate to severe pruritus receiving hemodialysis were enrolled. Difelikefalin (0.25, 0.5, and 1.0 μg/kg) and placebo were intravenously administered 3 times a week at the end of each hemodialysis session for 8 weeks. The primary end point was the change from baseline in the weekly mean Worst Itching Intensity Numerical Rating Scale (NRS) score at week 8. Secondary outcomes measured changes in itch-related quality-of-life score using the Skindex-16 and 5-D itch scale. Safety was assessed according to adverse events, laboratory tests, vital signs, body weight, and 12-lead electrocardiogram. A total of 247 Japanese patients (186 male [75%]; mean [SD] age, 64.5 [11.7] years) were randomized to placebo (n = 63), 0.25 μg/kg of difelikefalin (n = 61), 0.5 μg/kg of difelikefalin (n = 61), or 1.0 μg/kg of difelikefalin (n = 62). The changes from baseline in the adjusted mean (SE) of the 24-hour Worst Itching Intensity NRS score at week 8 were -2.86 (0.29) in the placebo group, -2.97 (0.29) in the 0.25 μg/kg of difelikefalin group, -3.65 (0.30) in the 0.5 μg/kg of difelikefalin group, and -3.64 (0.30) in the 1.0 μg/kg of difelikefalin group. Significant differences were found in the 0.5 μg/kg of difelikefalin group (adjusted mean difference, -0.80; 95% CI, -1.55 to -0.04; P = .04) and the 1.0 μg/kg of difelikefalin group (adjusted mean difference, -0.78; 95% CI, -1.54 to -0.03; P = .04) compared with placebo. The Skindex-16 overall score and 5-D itch scale total score indicated an improvement with treatment with 0.5 and 1.0 μg/kg of difelikefalin (adjusted weekly mean [SE] Skindex-16 overall score at week 8, -27.79 [2.05]; 95% CI, -31.83 to -23.74 for 0.5 μg/kg of difelikefalin and -22.69 [2.04]; 95% CI, -26.71 to -18.68 for 1.0 μg/kg of difelikefalin; adjusted weekly mean [SE] 5-D itch scale total score at week 8, -6.5 [0.4]; 95% CI, -7.2 to -5.8 for 0.5 μg/kg of difelikefalin and -6.8 [0.3]; 95% CI, -7.5 to -6.2 for 1.0 μg/kg of difelikefalin). The incidence of adverse events was 67% (42 of 63 patients) in the placebo group, 72% (44 of 61 patients) in the 0.25 μg/kg of difelikefalin group, 77% (47 of 61 patients) in the 0.5 μg/kg of difelikefalin group, and 85% (53 of 62 patients) in the 1.0 μg/kg of difelikefalin group. No dependency was reported. The findings of this phase 2 randomized clinical trial of difelikefalin suggest that 0.5 μg/kg of difelikefalin should be the clinically recommended dose as a new option for treating moderate to severe pruritus in patients undergoing hemodialysis because of its efficacy, acceptable tolerability, and manageable safety profile. ClinicalTrials.gov Identifier: NCT03802617.

Background: Cancer is an important comorbidity that can affect survival in dialysis patients. However, it is unclear if dialysis patients who develop cancer are disadvantaged by later detection and poorer prognosis. This study comparatively examined the stage at diagnosis and prognosis of several common cancer types in dialysis and nondialysis patients. Methods: In this retrospective cohort study, cancer registry data were linked with administrative data to identify dialysis and nondialysis patients with any new diagnosis of cancer between 2010 and 2015 at 36 hospitals in Osaka Prefecture, Japan. In these patients, we identified the cancer stage at diagnosis for patients with colorectal, stomach, lung, liver, kidney, and bladder cancers. The association between dialysis and survival time (up to 3 years of follow-up) was examined for each cancer type using Cox proportional hazards models that adjusted for age, sex, and cancer stage. Results: We analyzed 2,161 dialysis patients and 158,964 nondialysis patients with cancer. Dialysis patients had a higher prevalence of colorectal, liver, and kidney cancers than nondialysis patients. Colorectal, stomach, lung, liver, and kidney cancers were diagnosed earlier in dialysis patients, whereas bladder cancer was diagnosed at an advanced stage. The Cox proportional hazards models revealed that mortality was significantly higher in dialysis patients with colorectal, stomach, lung, and bladder cancers than in nondialysis patients (all p < 0.05). Conclusions: Dialysis patients had higher mortality for several common cancers despite their earlier detection. This poorer prognosis may be influenced by the unavailability and complications of cancer treatment for these patients.

ABSTRACTAlthough serum anti-glycopeptidolipid (GPL)-core IgA antibody is a highly specific test for infection with Mycobacterium avium complex (MAC), Mycobacterium abscessus, and its subspecies abscessus, subsp. massiliense, and subsp. bolletii (MAB), its use for the definitive diagnosis of MAC pulmonary disease (PD) and MAB-PD are unknown. To clarify the diagnostic accuracy of the anti-GPL-core IgA antibody test among patients with radiologically suspected MAC-PD or MAB-PD who already have a single positive sputum culture test. The first isolations of MAC and MAB from patients with radiologically suspected MAC-PD or MAB-PD at the Osaka Toneyama Medical Center between January 2006 and December 2020 were collected. Patients were enrolled when their serum anti-GPL-core IgA antibody was measured during the 3 months before and after the first isolation. We retrospectively compared the results of anti-GPL-core IgA antibody testing with the final diagnoses based on the current guidelines. We included 976 patients for analysis. The serum anti-GPL-core IgA antibody was positive in 699 patients (71.6%). The positive predictive value of anti-GPL-core IgA antibody for the diagnosis of MAC-PD or MAB-PD was 97.4%. The median time required for the second positive culture after the first isolation was 51 days (interquartile range 12 to 196 days). The positive serum anti-GPL-core IgA antibody test allowed an early and definitive diagnosis of MAC-PD or MAB-PD in those who already had a single positive sputum culture test.IMPORTANCE To satisfy the microbiologic criteria of the current diagnostic guideline for nontuberculous mycobacterial pulmonary disease (PD), at least two positive sputum cultures of the same species of mycobacteria from sputum are required to avoid the casual isolation of mycobacteria. This study showed that the positivity of a serum anti-glycopeptidolipid (GPL)-core IgA antibody test has an excellent diagnostic ability among patients with radiologically suspected Mycobacterium avium complex (MAC)-PD or Mycobacterium abscessus (MAB)-PD who already had a single positive sputum culture test. The usage of single culture isolation plus anti-GPL-core IgA antibody as another diagnostic criterion has a time, cost, and effort-saving effect. Furthermore, it will facilitate the diagnosis of MAC-PD or MAB-PD in the early stage of disease because serum anti-GPL-core IgA antibody becomes high in these patients. Therefore, we proposed adding single culture isolation plus anti-GPL-core IgA antibody as “combined microbiological and serological criteria” to the diagnostic guidelines for MAC-PD and MAB-PD.