Therapeutic Research

Background：Right ventricular（RV）apical pacing（RVA）is an important and effective treatment in patients with bradycardia or atrioventricular block. However, it is well‒known that RVA pacing promotes left ventricular（LV） dysfunction due to LV dyssynchrony. Real‒time 3D echocardiography（RT3DE）can evaluate LV mechanical dyssynchrony with regional LV dysfunction. Hence, 123I‒15‒（p‒iodophenyl）‒3‒R, S‒methyl pentadecanoic acid myocardial single photon emission computed tomographic（BMIPP‒SPECT）imaging can detect myocardial metabolic abnormality. Object：We assess global and regional LV function in patients after permanent cardiac pacemaker implantations on RVA, in terms of mechanical dyssynchrony and metabolic abnormality of LV using RT3DE and BMIPP‒SPECT. Method and Results：The subjects were 28 patients after pacemaker implantation （79.3±7.7 year‒old, 11 male, 54.8 month after implantation）without coronary heart disease. On RT3DE analysis, ejection fraction was 72.9±8.8％. Five patients had LV dyssynchrony. On regional analysis, early peak contraction located in apex and mid segments of septal and inferior wall. Delayed peak contraction were found more frequently on the basal of septal and inferior wall. Nineteen of 28 patients were performed BMIPP‒SPECT. Thirteen（69％）were found perfusion abnormality, which were located more frequently on the basal of septal and inferior wall. Delayed peak contraction on RT3DE and perfusion abnormality on BMIPP‒SPECT were good conformity （Cohen κ；0.79）. Conclusion：LV mechanical dyssynchrony and metabolic abnormality has a closely relation in this study. It seems to be necessary to evaluate LV function in various modality for risk stratification, even if LV systolic function are normal in patients after permanent pacemaker implantations.

Background：Patients with non‒dialysis chronic kidney disease（CKD）are widely instructed to have a protein‒restricted diet to inhibit progression of renal failure. However, patients with CKD are aging, and malnutrition is associated with poor prognosis. We retrospectively examined the association between mortality or renal prognosis in elderly patients with non‒dialysis CKD and the amount of protein intake, calculated using a 24‒hour cold storage pooled urine test. Methods：Of the 768 patients with CKD who visited Daiko Sunadabashi Clinic between September 2005 and August 2017, we included patients in whom cold storage 24‒hour pooled urine tests were performed at least once. The patients were divided into two groups―those with high and low normalized protein catabolic ratios（nPCRs）―and the outcomes and hazard ratios（HRs）were compared between the groups. The patients were also divided into groups based on age（65 and older or younger than 65 years）. The primary endpoint was mortality. The secondary endpoint was the induction of renal replacement therapy （RRT）. The baseline characteristics were tested using Student’s t‒test or a χ2 test. Survival was represented graphically using the Kaplan‒Meier method and analyzed using uni‒ and multivariate Cox regression analyses. Results：We assessed 233 men and 173 women with the age over 65. The mean age was 76.4±6.9 years. The mean creatinine clearance level was 48.0±36.3 mL/min/1.73 m2 and the mean nPCR was 0.888±0.285 g/day/kg. After adjustment, the nPCR was associated with mortality（HR：0.1849, 95％ confidence interval［CI］：0.0377‒0.9073, p＝0.0375）. The higher the nPCR, the higher the rate of RRT induction, but it was not significant（HR：2.3190, 95％ CI：0.8175‒6.5786, p＝0.1138）. An nPCR of 0.87051 was chosen as the cutoff value for the receiver operating characteristic curve to predict death. In patients under 65 years old, the rate of RRT induction tended to increase as the nPCR increased, but it was not significant. The nPCR value was unrelated to mortality. Conclusion：Restricting protein intake may be useful for suppressing progression of renal failure, but caution is necessary because restricting protein intake too severely in older people may be associated with deteriorated prognosis.

Objective：We had reported the efficacy of monthly oral ibandronate（IBN）100 mgcompared with monthly intravenous（IV）IBN 1 mg in the randomized double‒blind MOVEST study, and dose response was examined in the Phase Ⅱ study. We describe here the efficacy of both IBN treatments with respect to the suppression of the bone resorption markers. Material and Methods：Ambulatory Japanese patients aged≧55 years with primary osteoporosis were randomized to receive monthly oral IBN 100 mg＋monthly IV placebo, or monthly IV IBN 1 mg＋monthly oral placebo in the MOVEST study. The primary endpoint was non‒inferiority of oral vs IV IBN with respect to BMD gains at the lumbar spine after 12 months in the study. The changes of bone resorption markers such as urinary CTX, serum TRACP‒5b and urinary NTX were examined at baseline, 1, 3, 6, and 12 months. In the Phase Ⅱ study, the relative changes of urinary CTX were measured in details during the treatment duration. Results：The mean relative changes of both treatments from baseline in urinary CTX, serum TRACP‒5b and urinary NTX were similar throughout the treatment duration. The values of those three resorption markers did not express any exceeded suppression. The suppression of urinary CTX levels rapidly expressed and reached to the maximum. Conclusions：Both oral and IV IBN treatments expressed the time‒course suppression of bone resorption markers without excess.

背景：地域の介護予防事業として名古屋市では65 歳以上の高齢者を対象とした高齢者はつらつ長寿推進事業を実施している。目的：介護予防事業において薬剤師が認知症セミナーと認知症初期症状の自己チェックを推奨することで，参加者の認知症早期診断のための受診に与える影響を検討した。方法：2015 年10 月9 日～2017 年1 月16 日に，認知症セミナーの参加者194 名に認知症自己チェックを実施した。セミナー2 ヵ月後にかかりつけ医，もしくはもの忘れ相談医への受診状況を調査した。結果：認知症自己チェックで該当者が多かった項目は，「物の名前が出てこない」が129 名（66.5％），「物を置いた場所を忘れる」が106 名（54.6％），「2 つのことが一度にできない」が58名（29.9％）であった。セミナーから2 ヵ月後までに医療機関を受診した参加者は12 名であり，そのうち3 名にドネペジル塩酸塩が処方されていた。結論：高齢者はつらつ長寿推進事業における認知症自己チェックは，自立している高齢者の中に潜在している軽度認知障害の高齢者が受診を考えるきっかけになると考えられた。

Background: Self‒management education benefits people who have chronic diseases by increasing their self‒efficacy. However, those benefits decrease over time. This “decay of impact”makes reinforcement necessary, but reinforcement has not been effective, and the reasons are unknown. Purpose: This study was an analysis of the prevalence and the predictors of that decay of impact. Methods: Self‒efficacy was measured four times over one year. The participants were 384 adults who had various chronic medical conditions. They participated in chronic‒disease self‒management training. Logistic regression modeling was used to identify predictors of decay of impact. Results: Four pattern‒defined groups could be identified: improvement, decay of impact, deterioration, and no change. The prevalence of decay of impact was 39.8％. The final logistic‒regression model was a good predictor of having decay of impact. Conclusions: This shows how whole‒group statistics can mask important information about pattern‒defined groups, which can explain why previous studies have found only small effects, and why reinforcement generally seems to be ineffective. Reinforcement should be tested in those participants who are predicted to have decay of impact.