Our obstetricians and gynecologists manage pregnant women with conditions defined as high-risk pregnancies/deliveries by the Ministry of Health, Labour and Welfare of Japan. In some cases, these conditions become severe, resulting in premature delivery and subsequent admission of the neonates to the neonatal intensive care unit (NICU). However, it is unclear if high-risk pregnancies/deliveries also lead to a risk of NICU admission for term neonates. Here, we investigated whether high-risk pregnancies/deliveries that result in term deliveries increase the NICU admission rate for each factor that is considered high risk. We also focused on elderly primiparas at age 40 or greater as one high-risk factor and investigated whether it increases the NICU admission rate. Subjects were 2275 babies born after 37 weeks of gestation between January 2014 and December 2015. The NICU admission rate was significantly higher in the high-risk pregnancy (HR) group than in the low-risk pregnancy (LR) group (16.28% vs 3.79%, respectively; P <0.0001). The NICU admission rate was significantly higher for the elderly primipara group than for the control group (41.86% vs 4.50%, respectively; P <0.0001). Careful management is necessary for high-risk pregnancies as well as neonates at risk.
Dementia is one of the most serious problems in aging societies. A recent study has reported that higher serum coenzyme Q10 levels could reduce the risk of incident dementia. In this community-based study, we evaluated changes in serum ubiquinol level and cognitive performance following long-term intake of ubiquinol. Sixty-one residents (26 men, 35 women; aged 33-87 years) of Kamijima town in Ehime Prefecture agreed to participate in this study. The participants consumed 100-150 mg ubiquinol per day for 6 months to 2 years. We measured serum ubiquinol level and assessed cognitive performance using the 1-min Digit Symbol Substitution Test (DSST) both at baseline and after long-term ubiquinol intake. We also examined the subjects after a 3-month washout period. At baseline, a strong negative correlation was found between age and DSST score. There was no significant correlation between serum ubiquinol level and DSST score. Following long-term ubiquinol intake, both serum ubiquinol level and DSST score increased significantly. After the 3-month washout period, serum ubiquinol level decreased to almost the baseline level, whereas DSST score did not change significantly. Because this study is a single-arm trial these results should be considered carefully; nonetheless, our findings indicate the probable effects that long-term ubiquinol supplementation improves cognitive performance among community residents.
This study sought to demonstrate the benefits of conducting cervical cytology and human papillomavirus (HPV) testing in our cervical cancer screening program and was conducted between April 2012 and March 2017 in the Yuri-Honjo district of Akita Prefecture. A total of 3581 women aged 20-49 years underwent this combined screening for 5 years. Of these, 10.3% (369/3581) tested positive for HPV, and 433 women were initially diagnosed as positive for atypical squamous cells of undetermined significance and/or positive for HPV. Of those, 342 women (79.0%) underwent cervical biopsy, among whom 62 (18.1%) were diagnosed as positive for cervical intraepithelial neoplasia (CIN)2+. Of 204 women who were positive for HPV but showed no abnormalities in cytology, 24 women (11.8%) were positive for CIN2+ and 6 women were positive for CIN3+. Conventional cytology (Pap test) detected only 0.58% of the examinees positive for CIN2+ in Akita Prefecture, whereas our combined screening involving a Pap test and HPV testing detected 1.73% of the examinees (P<0.0001). We recommend HPV testing be used in combination with the Pap test to improve cervical cancer screening and accurately identify CIN2/3 disease.
Pneumonia is common among elderly patients and the incidence among older adults is increasing in aging societies. If pulmonologists were to treat all cases of pneumonia, their work volume would be immense and the risk of burnout would increase. We reviewed cases of consecutive patients 70 years of age or older who were treated for pneumonia between November 2017 and October 2018 at Akita Kousei Medical Center. Of a total of 372 patients recruited for this study (214 men, mean age 85.6 years), 288 patients recovered and 84 (29.2%) died. The duration of admission differed significantly between the cardiovascular department and surgery department (p=0.03), between the renal unit of the internal medicine department and the neurosurgery department (p=0.01), and the renal unit of the internal medicine department and the surgery department (p=0.0005). Outcome was not significantly different among departments. It is crucial that pulmonologists and non-pulmonologists collaborate to treat pneumonia in old adults.
As social conditions change, public health nurses with extensive practical skills should ideally be trained to meet social needs. The purpose of this study was to evaluate educational methods for public health nursing at Nursing School A from student self-evaluations using the Japanese Ministry of Health, Labour and Welfare's “Practical Competencies for Public Health Nurses and Achievement Level at Graduation” (hereinafter, “Practical Competencies assessment”) as well as other measures selected by the researchers. Students completed a questionnaire comprising 71 questions from the Practical Competencies and 3 questions on their' aspirations as a public health nurse before and after a public health nursing practicum course, and the results were compared. After the course, students were also asked to answer 8 questions related to group topic reports that were selected independently by researchers. The purpose of the study was explained to the participants in writing and their consent to participate was obtained. Responses were obtained from 53 students who selected the public health nursing track at Nursing School A (response rate and valid response rate both 100.0%). Achievement of competencies according to the Practical Competencies assessment did not differ significantly after the course, and the competency that was achieved by less than 70% of students was “III. Health crisis management”. Going forward, it will be necessary to examine curriculum and teaching methods used at the school to further enrich public health nursing education. The results also showed that students' aspirations as public health nurses after their practicum were to develop a nursing perspective and techniques unique to public health nursing and to expand the career options for public health nurses in the future, rather than simply to obtain the professional qualification. The results also suggested that preparing group topic reports greatly influences students by promoting group dynamics between students and proactive engagement with faculty and leadership.
Nutritional status tends to be poor in patients undergoing chemotherapy. We investigated anorexia caused by olfactory dysfunction by examining olfactory sense in chemotherapy patients and healthy volunteers. We used the Open Essence® olfactometry test, which assesses the accuracy of identifying 12 different odors. Twenty-seven patients (mean age 69.8 years) who received chemotherapy for lung cancer from March 2016 to September 2017 participated in multiple olfactometry examinations from the start of their chemotherapy. We also examined 284 healthy volunteers (mean age 41.9 years), and performed an additional subgroup analysis with 35 volunteers aged 60 years or older (mean age 73.2 years) to more closely align with the mean age of the patients. The mean accuracy rate was 44.4% for the patients, although this rate varied from odor to odor. In contrast, the mean accuracy rate of the healthy volunteers was 76.8%. There were significant differences according to sex and smoking history. For the subgroup of healthy volunteers aged 60 years and older, the mean accuracy rate was 54.5%; accuracy rate decreased as age increased. There was no significant difference in the accuracy rate according to type of chemotherapy, but the overall rate for patients was lower than that for healthy volunteers. Our results show that olfactory sense in lung cancer patients undergoing chemotherapy is altered compared with that in healthy individuals. Smoking habit was shown to have the greatest effect and most of the lung cancer patients in this study were smokers. A change in olfactory sense caused by smoking was also noted in the healthy volunteer group. We intend to conduct a similar investigation of patients with diseases other than lung cancer in the future as well as utilize the findings to investigate nutritional status.
Cisternography was performed using three weighted imaging techniques─constructive interference in steady state (CISS), sampling perfection with application optimized contrasts using different flip angle evolution (T2-SPACE), and T2-weighted imaging─in 15 patients with no history of intracranial lesions to determine which techniques are useful in diagnosis. Images were acquired using 1.5T and 3.0T magnetic resonance imaging (MRI) machines. The contrastnoise ratio (CNR) and the presence and number of artifacts were evaluated. CNR was highest for T2-SPACE and CISS. There were no significant differences in artifacts between the techniques with 1.5T MRI but significantly more artifacts in CISS images with 3.0T MRI. In conclusion, T2-SPACE imaging can produce cisternographic images with high contrast and few artifacts.
A 69-year-old woman was referred on suspicion of multiple bone metastases. She had undergone modified radical mastectomy for right breast cancer at age 40 years. Positron emission tomography revealed multiple bone metastases, and serum levels of CEA, CA15-3, and NCCST439 were elevated. The diagnosis was metastatic breast cancer. Pathological re-examination confirmed that the tumor cells were positive for estrogen receptor and progesterone receptor, and negative for HER2. Endocrine therapy with letrozole was initiated, followed by toremifene citrate as second-line therapy and exemestane as third-line therapy. Seventeen months later, she developed trouble walking because of lower-extremity edema, which was caused by a synovial cyst of the left hip joint. Although no other metastases were detected, S-1 was introduced (2 weeks followed by 1 week of rest) due to severe decline in quality of life. Six months after initiation of S-1, the synovial cyst disappeared and lower-extremity edema was improved. At 11 months after initiation of S-1, serum CA15-3 level had fallen to approximately within normal limits. As of now, although the tumor marker level has been rising gradually, no other metastases except for bone metastases have been detected and treatment is continuing.
We monitored the glucose levels of 3 patients who had undergone total gastrectomy without hypoglycemic symptoms using the Free Style Libre Pro®, a continuous glucose monitoring system, and assessed fluctuations. Mean patient age was 75±3 years and all were men. The highest and lowest sensor glucose (SG) values were 337±54 mg/dL and 44±8 mg/dL, respectively. In 2 of the 3 patients, the lowest SG value was 40 mg/dL, which was the lower limit of detection. After administration of alpha-glucosidase inhibitors, all patients showed improvement in the highest and lowest SG values, and the proportion of time when the SG value was 180 mg/dL or above decreased. The proportion of time when the SG value was less than 70 mg/dL increased in 2 of the 3 patients. However, mean SG values during the same time periods were higher than the pretreatment values, and the proportion of time when the value was less than 60 mg/dL decreased. Consensus error grid analysis performed using blood glucose levels from selfmonitored measurements and meal tolerance tests taken during continuous glucose monitoring versus SG values revealed that all data pairs were within the clinically acceptable regions (zones A and B).
Patient 1 was a 73-year-old woman with chief complaints of abdominal pain and prolapse of bowel through the anus. About 10 cm of the intestine had prolapsed through the anus, and a mass was observed at the invasive front. Computed tomography (CT) revealed the classic target sign of an intussusceptum inside an intussuscipiens, where the sigmoid colon had intussuscepted into the rectum. Patient 2 was a 92-year-old woman who presented with a chief complaint of melena. About 5 cm of the intestine had prolapsed through the anus, and a mass was observed at the invasive front. CT showed the classic target sign in the rectum. Based on physical examination and CT findings, both cases were diagnosed as intussusception caused by progression of colorectal cancer. Manipulative reduction was attempted before surgery, but neither intussusception could be reduced and thus Hartmann’s operation was performed for both patients. Patient 1 had an uneventful postoperative course and was discharged on hospital day 36. Patient 2 developed prolonged paralytic ileus due to unsuccessful mobilization and was discharged on hospital day 80. Abdominoperineal resection is required for irreducible prolapse of intussusception through the anus due to colorectal cancer, and this invasive procedure can cause complications. Many patients with this condition are elderly adults with weak pelvic supporting tissue, and thus treatment suited to each individual patient must be selected.
A 17-year-old male was admitted to our hospital because of strong abdominal pain. His symptoms gradually worsened even after hospitalization, and contrast computed tomography (CT) revealed hemorrhage in the abdominal cavity. Interventional radiology (IVR) was performed to identify the bleeding site. No obvious source of bleeding was identifiable on IVR, so we opted to perform laparoscopic examination and hemostasis. The intraperitoneal finding was hematoma in the omentum, and omentectomy was performed for idiopathic omental hemorrhage because there was no history of trauma. The postoperative course was good and the patient was discharged after postoperative day 4. Performing laparoscopic surgery for omental hemorrhage facilitated minimally invasive treatment with a short hospital stay.
We report here 2 cases of traumatic diaphragmatic hernia. Case 1 was a 76-year-old man who was injured in a road traffic accident (RTA). Chest X-ray and computed tomography (CT) revealed prolapse of the stomach into the left thoracic cavity. We performed laparotomy with a diagnosis of traumatic left diaphragmatic hernia. A 12-cm hole was seen in the central tendon of the left diaphragm and this was repaired by suturing. Case 2 was a 75-year-old man who was also injured in an RTA. Chest X-ray and CT revealed prolapse of the stomach and transverse colon into the left thoracic cavity. We performed laparotomy with a diagnosis of traumatic left diaphragmatic hernia. A 15-cm hole was seen in the central tendon of the left diaphragm and this was repaired by suturing. Traumatic diaphragmatic hernia is a relatively rare condition and one that requires surgical repair. It is important to make prompt diagnosis with appropriate radiological investigations. Additionally, patients with diaphragm hernia caused by blunt trauma often have injuries to other organs. Care should be taken so as not to miss associated injuries.
Trousseau's syndrome is a condition in which thromboembolic events are triggered by hypercoagulation caused by a malignancy. Here, we report two cases in which gynecologic cancer was detected after cerebral infarction. Patient 1 was a 66-year-old gravida 0, para 0 who presented with left-sided arm and leg weakness. Head magnetic resonance imaging (MRI) facilitated a diagnosis of cerebral infarction. Subsequent contrast computed tomography (CT) revealed an ovarian tumor, and she underwent surgery on day 8 after admission. The tumor was diagnosed as ovarian clear cell carcinoma on pathological examination. She received adjuvant chemotherapy and the cancer has not progressed in more than 2 years after the surgery. Patient 2 was a 41-year-old gravida 1, para 1 who presented with impairment of consciousness, right hemiplegia, and aphasia. Head MRI facilitated a diagnosis of cerebral infarction. Contrast MRI and contrast CT findings were suggestive of endometrial cancer, and she underwent surgery on day 19 after admission. The cancer was diagnosed as grade 3 endometrial cancer on pathological analysis. She received adjuvant chemotherapy and the cancer has not progressed in more than 4 years after the surgery. Although treatment of the primary disease is considered to affect prognosis in Trousseau’s syndrome, many patients have poor survival prospects because, when detected, their cancer is too advanced to be treated surgically. These cases illustrate the need for close cooperation with other departments such as neurology and cerebrovascular surgery to ensure that these cancers are diagnosed quickly and the opportunity to start multimodality treatment is not missed.
We report here a case of hilar breast cancer metastasis identified incidentally during lung resection for lung cancer. The patient had a past history of triple negative breast cancer diagnosed at another hospital. A malignant hilar node was detected, which could not easily be distinguished as metastasis from the lung adenocarcinoma or from the breast cancer. Previous studies have investigated lymphatic flow changes by axillary sentinel lymph node biopsy or dissection. When an unknown lymphadenopathy is detected in a patient with a past history of breast cancer, metastatic breast cancer should be considered.
Due to rapid aging of the Japanese population, it is expected that by 2025 the number of elderly adults with dementia will exceed previous projections. The number of admissions of elderly patients with dementia has also been increasing on Ward A, and staff have been grappling with the challenge of managing behavioral and psychological symptoms of dementia (BPSD) such as wandering, anxiety, restlessness, lack of motivation, delirium, hallucinations, delusions, and sleep disorders. Dementia is a disease that threatens the intellectual capabilities that people accumulate throughout their lifetime. Taktil® care was provided to elderly inpatients with dementia who had an Abe’s BPSD score of 13 or higher on admission, and changes in score were evaluated after provision of care. Abe’s BPSD score decreased significantly in all patients (Wilcoxon signed-rank test). This indicates that Taktil® care enabled nurses to calm elderly patients with dementia and build a trusting relationship with them, and this reduced restlessness and abnormal behavior. This care approach produced results in just the short time that patients spent on the general ward, demonstrating that it is an effective form of nursing care for elderly adults with dementia who have BPSD.
A questionnaire was administered to identify differences between the information that ward nurses think should be provided on a discharge summary and the information that outpatient nurses consider is necessary for providing continuing nursing care. Respondents were asked to select from multiple choice answers which information they believe is necessary to provide on a discharge summary and their perceptions about continuing nursing care, and they were also asked to record the reasons for their selections. Multiple choice responses were aggregated by simple tabulation and reasons were aggregated by similarity. The results showed that ward nurses and outpatient nurses had the same perceptions of what information is needed on a discharge summary. However, whereas the outpatient nurses wanted to see specific information about what care should be continued on the discharge summary, the ward nurses considered continuing nursing care to mean sharing summarized information about the patient's hospital course. This difference can be attributed to the unique characteristics of ward nurses and outpatient nurses. To provide continuing nursing care, ward nurses and outpatient nurses should each understand the other's thinking and learn what information the other considers necessary.