急性期脳梗塞患者における血液透析は短期あるいは長期死亡の危険因子である

慢性腎臓病は脳血管障害を含む心血管疾患の独立した危険因子である．透析患者の脳卒中発症リスクは非透析患者に比較して高い事が報告されている．しかし，血液透析施行と，急性期脳梗塞患者の短期及び長期死亡の関連は不明である．今回我々は，急性期脳梗塞患者における院内死亡及び退院１年後の死亡に透析が関与するかどうか検討した．2007年４月～2015年３月に当科に入院した発症24時間以内の脳梗塞患者を後ろ向きに検討した．血液透析の有無により，血液透析あり群となし群に分類し，臨床背景を比較した．加えて末期腎不全患者（eGFR15ml 分/1.73m2以下）において，血液透析あり群となし群に分類し，臨床背景を比較した．更に院内及び退院後１年以内の死亡の有無により生存群と死亡群に分けて，血液透析を含む関連因子を多変量解析で検討した．急性期脳梗塞1,894例が登録された．平均年齢は73.8±11歳，男性は1,122人（59.2%）であった．65例（3.4%）が維持透析中であった．透析群と非透析群の背景因子の比較について示す．年齢（69.6±11.9 vs. 73.7±12歳　P ＝0.013）は透析群が有意に若く，高血圧の既往（91% vs. 70% P<0.001），糖尿病の既往（45% vs. 24% P<0.001），脳底動脈の閉塞（7% vs. 2% P=0.001）が透析群では有意に高かった．また全体の院内死亡率は5.3%（96/1,894人）であった．透析群は非透析群と比較して院内死亡率（14% vs. 5% P=0.001）は有意に高かった．末期腎不全患者間でも，透析群は非透析群と比較して院内死亡率（15% vs. 0% P=0.038）は有意に高かった．院内死亡群と生存群に分けて多変量解析をしたところ入院時の年齢（オッズ比（OR）1.1，95%CI1.02-1.23，P=0.013），入院時NIHSS 高値（OR1.2，95%CI1.12-1.38，P=0.012），脳底動脈の閉塞（OR3.3，95%CI1.32-3.84，P=0.011），透析群（OR7.8，95%CI2.259-26.79，P=0.001）が独立した関連因子であった．次に退院後１年以内の死亡率は7.9%（226/1,798人）であった．透析群は非透析群と比較して１年後死亡率（21% vs. 12%, P=0.001）は有意に高かった．末期腎不全患者間でも，透析群は非透析群と比較して院内死亡率（22% vs. 8%，P=0.042）は有意に高かった．１年以内の死亡率と生存群に分けて多変量解析を実施したところ年齢（OR1.1，95%CI1.07-1.28， P=0.014），内頚動脈の閉塞（OR1.9，95%CI1.34-4.62， P=0.009），退院時mRS3-5（OR2.3，95%CI1.6-3.2，P=0.008），透析群（OR2.5，95%CI1.34-4.62，P=0.001）が独立した危険因子であった．以上より血液透析は脳梗塞後の短期及び長期死亡の因子である．The chronic kidney disease is an independent risk factor of the cardiovascular diseases including stroke. Hemodialysis (HD) is reported to be a risk factor for cerebrovascular events. However, it is unclear whether HD is a risk factor for short or long term mortality in ischemic stroke patients. The aim of the present study was to investigate the whether a short or long term mortality of stroke patients receiving HD is higher than that of those without HD. From April 2007 to May 2015, we retrospectively enrolled ischemic stroke patients within 24h of stroke onset who were admitted to our hospital. We divided the patients into two groups according to presence and absence of receiving HD (HD group and non-HD group). Additionally, we divided the patients with end stage renal failure (<eGFR15ml/min/1.73m2) into HD group and non-HD group. We compared the clinical characteristics and the mortality rate at discharge and 1year after stroke onset between the two groups. The factors associated with death were investigated by multivariate logistic regression analysis. 1894 patients (1,122 males; (59.2%), mean age 73.8 ± 12 years) were enrolled. 65 patients (3.4%) had HD. HD group was younger (69.6 ± 11.9 vs. 73.7 ± 12.0 year, P = 0.013), and hypertension (91 % vs. 70 %, P < 0.001) diabetes mellitus (45% vs. 24%, P < 0.001) and basilar artery occlusion (7 % vs. 2%, P = 0.001) were more frequently observed than in the non-HD group. In-hospital mortality was 5.3% (96/1,894 patients). HD group had a high mortality rate compared with non HD group (14%vs. 5%, P=0.001). In end stage renal failure, HD group had a high mortality rate compared with the non HD group (15% vs. 0%, P = 0.038). Multivariate logistic regression analysis demonstrated that age per 1year increase (OR 1.1, 95%CI 1.02-1.23, P = 0.013), higher NIHSS score on admission, (OR 1.2, 95% CI 1.12-1.38, P = 0.012), basilar artery occlusion (OR 3.3, 95% CI 1.32-3.84, P = 0.011), and HD (OR 4.1, 95%CI 1.73-9.97, P = 0.001) were independent factors associated with in-hospital death. Next, after hospital discharge, 7.9% of patients died within 1 year. HD group had a high mortality rate compared with the non HD group (21% vs. 12%, P = 0.001). In end stage renal failure, HD group had a high mortality rate compared with the non HD group (22% vs. 8%, P = 0.042). On multivariate regression analysis, age per 1year increase (OR 1.1, 95%CI 1.07-1.28, P = 0.014), poor functional outcome (modified Ranking Scale (3-5)) at discharge (OR 2.3, 95%CI 1.64-3.23, P = 0.008), Internal carotid artery occlusion (OR 1.9, 95% CI 1.23-3.34, P = 0.009) and HD (OR 2.5, 95%CI 1.34-4.62, P = 0.001) were independent factors associated with death within 1year of stroke onset. Therefore, HD was independently associated with short or long term mortality

Cementless total hip replacement: past, present, and future

Cementless total hip replacement (THR) is rapidly being accepted as the surgery for arthritic diseases of the hip joint. The bone-ingrowth rate in porous-type cementless implants was about 90% over 10 years after surgery, showing that biological fixation of cementless THR was well maintained on both the stem and cup sides. As for the stress shielding of the femur operated using a distal fixation-type stem, severe bone resorption was observed. The severe bone resorption group showed continuous progression for more than 10 years after surgery. Stem loosening directly caused by stress shielding has been considered less likely; however, close attention should be paid to bone resorption-associated disorders including femoral fracture. Cementless cups have several specific problems. It is difficult to decide whether a cup should be placed in the physiological position for the case of acetabular dysplasia by bone grafting or at a relatively higher position without bone grafting. The bone-ingrowth rate was lower in the group with en bloc bone grafting, and the reactive line was frequently noted in the bone-grafted region. Although no data indicated that en bloc bone grafting directly led to poor outcomes, such as loosening, cup placement at a higher site without bone grafting is now selected by most operators. The polyethylene liner in a cementless cup is thinned due to the metal cup thickness; however, it has been suggested that the apparent relation between the cup size and the wear rate was absent as long as a cementless cup is used. Comparative study indicated cementless THR was inferior with regard to the yearly polyethylene wear rate and incidence of osteolysis on both the stem and cup sides. Meta-analysis study on the survival rate between cement and cementless THR reported that cemented THR was slightly superior. It should be considered that specific problems for cementless THR, especially with regard to polyethylene wear, do occur

Validation of Optimum ROI Size for 123I-FP-CIT SPECT Imaging Using a 3D Mathematical Cylinder Phantom

Objective(s): The partial volume effect (PVE) of single-photon emission computedtomography (SPECT) on corpus striatum imaging is caused by the underestimation ofspecific binding ratio (SBR). A large ROI (region of interest) set using the Southamptonmethod is independent of PVE for SBR. The present study aimed to determinethe optimal ROI size with contrast and SBR for striatum images and validate theSouthampton method using a three-dimensional mathematical cylinder (3D-MAC)phantom.Methods: We used ROIs sizes of 27, 36, 44, 51, 61, 68, and 76 mm for targets withdiameters 40, 20, and 10 mm on reference and processed images reconstructed usingthe 3D-MAC phantom. Contrast values and SBR were compared with the theoreticalvalues to obtain the optimal ROI size.Results: The contrast values in the ROI with diameters of 51 (target: 40 mm indiameter) and 44 (target: 20 mm in diameter) mm matched the theoretical values.However, this value did not correspond with the 10-mm-diameter target. The SBRmatched the theoretical value with an ROI of > 44 mm in the 20-mm-diameter target;but, it was under- and overestimated under any other conditions.Conclusion: These results suggested that an ROI should be 4-2 folds larger thanthe target size without PVE, and that the Southampton method was remarkablyaccurate

Development and Validation of the Japanese Version of the Consensus Auditory-Perceptual Evaluation of Voice

PURPOSE: Auditory-perceptual evaluation is essential for the assessment of voice quality. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) provides a standardized protocol and assessment form for clinicians to analyze the voice quality and has been adapted into several different languages. The aims of this study were to develop the Japanese version of the CAPE-V and to investigate its reliability and validity. METHOD: The Japanese CAPE-V consisted of the same three speech contexts (vowels, sentences, and conversation) as developed in the original English version. The sentences were designed according to the concepts of the original version and reviewed by Japanese phoneticians. To validate the usefulness of the Japanese CAPE-V, voices of 173 Japanese-speaking subjects (76 subjects with dysphonia and 97 without voice complaints) were evaluated by five experienced judges, according to the Japanese CAPE-V as well as the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale. RESULTS: The Japanese CAPE-V provided a high interrater reliability (intraclass correlation coefficients [ICCs] > .85 for all the parameters) as well as a high intrarater reliability (ICCs > .85 for all the parameters). In addition, overall severity, roughness, and breathiness in the Japanese CAPE-V were highly correlated with the corresponding dimensions in the GRBAS scale, having Spearman correlation coefficients greater than .8. CONCLUSION: This study demonstrated the reliability and validity of the newly developed Japanese CAPE-V as an auditory-perceptual evaluation instrument