Three-year trajectories of social networks, face-to-face interactions, and non-face-to-face interactions among community-dwelling older adults in Japan during the COVID-19 pandemic: Otassha study

OBJECTIVES

To investigate the trajectories of social networks and interactions among older Japanese individuals during the COVID-19 pandemic.

STUDY DESIGN

We used data from a cohort of community-dwelling older individuals from the Otassha study's 2019-2022 survey. Participants comprised 606 older individuals who participated in the 2019 survey and were followed up at least once.

MAIN OUTCOME MEASURES

Social networks were assessed using the Lubben Social Network Scale-6 (LSNS-6), whereas social interactions were assessed by the frequency of face-to-face or non-face-to-face contact with non-resident family members and friends. Trajectories of the LSNS-6 and face-to-face and non-face-to-face interactions were identified using group-based semiparametric mixture modeling. The trajectories of change in the LSNS-6 from 2019 were also identified. The factors associated with the changes in trajectory patterns were examined using logistic regression analysis.

RESULTS

Three LSNS-6 trajectories were identified, with slightly decreasing patterns over time. Specifically, face-to-face interactions tended to decrease over time, whereas non-face-to-face interactions exhibited almost no change. The reduction in LSNS-6 in the decreased pattern failed to recover to its pre-pandemic level. The group of participants with the decreased pattern had a significantly higher proportion of people participating in group activities [odds ratio (95 % confidence interval): 2.27 (1.12-4.59)] and performing calisthenics twice a week than the group with the maintained pattern [2.08 (1.18-3.68)].

CONCLUSIONS

During the three years of the pandemic, no changes were observed in the social networks of community-dwelling older Japanese individuals.

Social isolation, regardless of living alone, is associated with mortality: the Otassha study

Introduction

Social isolation has been recognized as a contributing factor to negative health outcomes. Although living alone is associated with health-related outcomes, existing findings are inconsistent. It is not the act of living alone that may predict poor health, but rather social isolation that can lead to increased mortality risk. This study investigated the combined associations of social isolation and living alone with mortality among community-dwelling older adults.

Methods

We included older adults from Itabashi ward, Tokyo, who participated in comprehensive health checkups. Participants were categorized into four groups based on their social isolation status and living alone. The primary outcome was all-cause mortality, analyzed using Cox proportional hazards models.

Results

Of the 1,106 participants (mean age 73, 42% male), 4.5% experienced both social isolation and living alone. This combination was associated with a worse prognosis regarding all-cause mortality (hazard ratio (HR): 2.08 [95% confidence interval (CI), 1.08-4. 00]). Those who were socially isolated but not living alone also showed a trend towards higher mortality risk (HR: 1.41 [95% CI, 0.90-2.20]). Contrastingly, those who were not socially isolated and lived alone did not show an increased mortality risk (HR: 0.81 [95% CI, 0.44-1.49]).

Discussion and conclusion

Living alone is not inherently associated with a poor prognosis in older adults; however, social isolation was associated with a higher mortality risk. Healthcare providers should focus on enhancing social interactions and support for older adults because of their effects on health rather than solely addressing living arrangements to prevent adverse health events.

Predicting the incidence of mild cognitive impairment with a computer-based cognitive assessment tool in community-dwelling older adults: The Otassha study

This study examined the ability of a computer-based cognitive assessment tool (CompBased-CAT) to predict mild cognitive impairment (MCI) in community-dwelling older adults. A two-year longitudinal study was conducted using data from 2016 to 2018 from the Otassha study cohort of community-dwelling older adults. MCI was defined as a Mini-Mental Status Examination (MMSE) score of <27. The CompBased-CAT was used at baseline, with each subtest score converted into a Z-score. Subsequently, the total Z-scores were calculated. Participants were divided into robust and MCI groups, and all variables were compared using the t-test or χ2 test. Receiver operating characteristic (ROC) curves and logistic regression analyses were conducted, with MCI and total Z-scores as dependent and independent variables, respectively. Among the 455 participants (median age, 72 years; range, 65-89 years; 282 women and 173 men), 32 developed MCI after two years. The participants in the MCI group were significantly older. They had lower maximal gait speed, baseline MMSE scores, subtest Z-scores, and total Z-scores than those in the robust group. The area under the ROC curve was 0.79 (95% confidence interval: 0.70-0.87; P <0.01). The sensitivity was 0.76, and the specificity was 0.75. The logistic regression analysis showed an odds ratio of 1.34 (95% confidence interval: 1.18-1.52; P <0.01). This study showed that CompBased-CAT can detect MCI, which is an early stage of dementia. Thus, CompBased-CAT can be used in future community health checkups and events for older adults.

Development and validation of a rapid sarcopenia screening questionnaire: The Otassha study

AIM

To develop a rapid and easy screening tool to detect sarcopenia.

METHODS

In total, 683 community-dwelling older adults who participated in our cohort study, the "Otassha Study," in 2019, completely responded to a questionnaire, and were diagnosed with sarcopenia were included. Participants responded to a nine-item questionnaire, including candidate items for a new sarcopenia screening tool named rapid sarcopenia screening, based on items of the Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls (SARC-F) questionnaire. To select appropriate items for the new screeening tool, multiple logistic regression analyses were performed, with sarcopenia as the dependent variable and questionnaire responses as independent variables. The area under the curve using 10 000 bootstraps was used to assess the rapid sarcopenia screening diagnostic ability for detecting sarcopenia.

RESULTS

Responses to question nos 2 (how much can you squeeze a wet towel?), 5 (how much muscle strength do you think you have compared with that of people of your age and sex?), 7 (how fast do you usually walk?), and 9 (age-related item) were related to sarcopenia in multiple logistic regression analysis. The area under the curve of the total score of rapid sarcopenia screening was 0.82, 0.80, and 0.81 for men, women, and overall, respectively. At a cut-off value of 14/15, the sensitivity and specificity for sarcopenia detection were 0.73 and 0.73, respectively.

CONCLUSIONS

The newly developed sarcopenia screening tool has a better diagnostic ability for sarcopenia than the SARC-F. Rapid sarcopenia screening does not require physical function measurements, making it a useful and accessible tool among older adults to detect sarcopenia. Geriatr Gerontol Int 2023; 23: 945-950.

Impact of combinations of subscale declines in higher-level functional capacity on 8-year all-cause mortality among community-dwelling older Japanese adults

BACKGROUND

The frequency of combined declines in domains of multi-faceted frailty and their impact on adverse health outcomes have not been adequately investigated. We aimed to examine the association between combined subscale declines in higher-level functional capacity and 8-year all-cause mortality among community-dwelling older Japanese individuals and the impact of multi-faceted frailty on mortality.

MATERIALS AND METHODS

We administered a questionnaire to 7015 community-dwelling older adults aged 65-85 years. The higher-level functional capacity of the 3381 respondents was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence. Subscale decline was defined as (1) none, (2) only social role (SR), (3) only intellectual activity (IA), (4) SR and IA, (5) only instrumental activities of daily living (IADL), (6) IADL and SR, (7) IADL and IA, and (8) all. Associations between combined subscale declines and mortality were examined using adjusted Cox proportional hazards models. Follow-up was conducted from October 1, 2012, to death or November 1, 2020.

RESULTS

The mortality rate was 16.7/1000 person-years. Moreover, 44% of respondents had declined SR, and half of them had multiple declines. Compared with no decline, SR (adjusted hazard ratio [HR]: 1.49, 95% confidence interval [CI]: 1.14-1.93), SR and IA (HR: 1.59, 95% CI: 1.16-2.17), IADL and SR (HR: 1.97, 95% CI: 1.31-2.99), and all-domain (HR: 2.72, 95% CI: 1.98-3.74) declines were significantly associated with higher mortality risks.

CONCLUSIONS

Overlapping SR and IADL declines increased mortality risk, suggesting the importance of measuring social frailty and overlapping physical and social frailty.

Social interaction trajectories and all-cause mortality in older adults: the Otassha study

Introduction

This longitudinal study aimed to identify aging trajectory patterns of social interaction by sex and determine the association between these patterns and all-cause mortality.

Methods

Participants were 4,065 community-dwelling older adults (1849 men) in Japan, aged 65-89 years, who responded twice or more to a mail survey conducted between 2012 and 2020. Social interaction was examined through the frequency of face-to-face and non-face-to-face contact with non-resident family and friends. The aging trajectories of the social interaction scores were identified using group-based trajectory modeling.

Results

Two groups were identified among both men and women. Among men with high-frequency interaction, a rapid decrease in the frequency of social interaction was observed after 80 years of age. Conversely, among women, the frequency tended to remain the same, even after 80 years of age. The social interaction score among those aged 65 years in the low-frequency group was approximately 4 points for men and 6 points for women. Among men, no decrease was observed; however, it tended to decline after 85 years of age among women. Among men, the factors associated with the low-frequency group were instrumental activities of daily living score, perceived financial status, and social participation, while among women, they were self-rated health and social participation. The adjusted hazard ratio in the low-frequency group for all-cause mortality was 1.72 (95% confidence interval, 1.27-1.72) for men and 1.45 (95% confidence interval, 0.98-2.14) for women.

Discussion

In the low-frequency group, men had a higher risk of all-cause mortality than women. Daily social interaction from mid-age is important to reduce the risk of social isolation and all-cause mortality in later life.

[Sub-staff training program for community residents to provide community-based care services at day-care facilities]

Objectives As the birthrate declines and the population ages, increase in the number of older adults certified as requiring long-term care and shortage of care staff are important issues to be considered. This study developed a sub-staff training program that trains community residents as sub-staff (paid auxiliary staff who possess knowledge and skills in care prevention and confidentiality) to provide care for enhancing independence of older adults with the support of staff in day-care facilities. The study also examined the program's feasibility and key factors, through the introduction of practical examples and surveys, for implementation in care prevention projects of local governments.Methods The four-month training program included lectures on care prevention and provided job training to ensure participants understood the goals and contents of the care plan and learnt to provide care services with the assistance of facility staff. The training program was conducted at 14 facilities in Tokyo and Chiba from 2015 to 2017. The evaluation focused on the completion rate, change in understanding of care prevention and confidence regarding activities at the facility and in the community, participation in community activities after program completion, the psychological impact on care service recipients, and the perception of workload reduction by the facility staff.Results A total of 96 out of 104 participants completed the training program (completion rate of 92.3%). The survey results showed that participants' confidence in activities at the facilities and understanding of care prevention increased significantly; 65.3% participated in new community activities after program completion, including activities at the facilities. The results of the survey of care service recipients showed that negative psychological effects did not increase among those who received care services from the participants compared to those who did not receive care from participants. Among the facility staff, 85.7% indicated that their workload had reduced after the community residents' participation in care services.Conclusion The training program improved participants' confidence in care-related activities and their understanding of care prevention. More than half of them engaged in new community activities afterwards. Participants' provision of care services had a less negative impact on the service recipients and led to a reduction in workload for the facility staff. These results suggest high feasibility of the training program for care prevention projects.

Population-based reference values for tongue pressure in Japanese older adults: A pooled analysis of over 5,000 participants

PURPOSE

To establish age- and sex-specific population reference values for tongue pressure (TP) in community-dwelling Japanese older adults.

METHODS

For this analysis, we pooled four population-based studies on community-dwelling adults aged ≥65 years that measured TP using a JMS tongue pressure measuring device. We calculated the means and deciles of TP per 5-year age group for each sex. We also estimated age trends in TP for men and women.

RESULTS

In total, 5,083 individuals (2,150 men and 2,933 women, with a mean [standard deviation] age of 75.2 [6.5] years) were included in the present analysis. In male participants, the mean (standard deviation) TPs for ages 65-69, 70-74, 75-79, 80-84, and ≥85 years were 34.0 (8.4), 32.2 (8.1), 30.8 (8.3), 28.4 (8.9), and 24.4 (8.2) kPa, respectively. In female participants, the corresponding values were 31.5 (7.1), 30.5 (7.5), 29.6 (7.3), 28.4 (8.0), and 26.4 (7.6) kPa, respectively. For both sexes, there were significant declining trends in TP with advanced age. In addition, the interaction between age and sex had a significant effect on TP (regression coefficient [95% confidence interval] = -0.18 [-0.25 to -0.11] when age was modeled as a continuous variable and sex was modeled as a categorical variable [coded as 0=women, 1=men]).

CONCLUSIONS

This study determined age- and sex-specific reference values for TP, presented as means and deciles, in community-dwelling Japanese older adults aged ≥65 years. This study also demonstrated sex differences in age-related declines in TP.

Association between daily life walking speed and frailty measured by a smartphone application: a cross-sectional study

OBJECTIVES

To assess whether frailty can be assessed using a smartphone and whether daily walking speed (DWS) is associated with frailty.

DESIGN

Cross-sectional study.

SETTING

Three prefectures (Kanagawa, Saitama and Tokyo) in Japan.

PARTICIPANTS

The study enrolled 163 participants (65 in the robust group, 69 in the prefrailty group and 29 in the frailty group) by sending letters to house owners aged≥55 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The participants downloaded the DWS measurement application on their smartphones, which measured the daily walking (DW) parameters (DWS, step length and cadence) and the Kihon checklist for frailty assessment. The differences in the DW parameters between the robust, prefrailty and frailty groups were examined using one-way analysis of variance. We conducted logistic regression analysis for the Crude model (each DW parameter), model 1 (adjusted for the number of steps) and model 2 (model 1+age, sex and the number of chronic diseases).

RESULTS

DWS was marginally significantly slower in the frailty group than in the prefrailty and robust group (robust 1.26 m/s vs prefrailty 1.25 m/s vs frailty 1.19 m/s, p=0.060). Step length was significantly smaller in the frailty group than in the robust group (robust 66.1 cm vs prefrailty 65.9 vs frailty 62.3 cm, p<0.01). Logistic regression analysis for the three models revealed that DWS was significantly associated with frailty.

CONCLUSIONS

DWS measured using the smartphone application was associated with frailty. This was probably due to the shorter step length and body height seen in frail individuals.

Activity diversity is associated with the prevention of frailty in community-dwelling older adults: The Otassha Study

Introduction

A prior study showed an association between diversity in daily activities (type, frequency, evenness) and frailty in older adults. However, the causality of this relationship is unclear. Therefore, this study aimed to clarify the relationship between activity diversity and frailty through a 2-year longitudinal study conducted among community-dwelling older adults.

Methods

We evaluated data from the 2018 and 2020 waves of the Otassha Study. Frailty was assessed using the Cardiovascular Health Study criteria, with pre-frail and frail participants defined as frail and the other participants categorized into the robust group. We enrolled a total of 207 participants who were not frail at baseline. Activity type, frequency, and evenness scores were calculated using an Activity Diversity Questionnaire. The association between each activity diversity score and the incidence of frailty was evaluated using logistic regression modeling (each diversity score was entered the model after Z-transformation).

Results

Of the 207 enrolled participants (median age, 73 years; age range, 65-91 years; 60.4% women), 64 (30.9%) had incident frailty during the follow-up period. A logistic regression analysis adjusting for sociodemographic and psychosomatic factors revealed odds ratios for activity type and evenness scores of 0.64 and 0.61, respectively (P < 0.05). These factors were significantly associated with the incidence of frailty.

Discussion

Activity type and evenness (except frequency) within daily activities were predictors of frailty during 2 years of follow-up. Engagement in diverse activities appears to be more effective in preventing frailty than does engagement in a few activities.

The trajectory of psychological well-being during the COVID-19 pandemic and its association with health-promoting coping behavior among Japanese community-dwelling older adults: The Otassha Study

This study aims to identify the trajectory of psychological well-being during the COVID-19 pandemic among community-dwelling older adults and to clarify the association between coping behavior in the early stage of the pandemic and the trajectory of psychological well-being. The study was based on a cohort study, known as "the Otassha Study." We administered three follow-up surveys to 720 older adults who participated in the survey in October 2019 (T0): T1: June 2020, T2: October 2020, and T3: October 2021. Furthermore, we assessed coping behavior in T1 via a self-developed questionnaire comprising 10 items. Psychological well-being was assessed by the WHO-5 Well-Being Index (score range: 0 to 25) in all surveys. The trajectories of psychological well-being were identified by group-based trajectory modeling. The association between coping behaviors and trajectory patterns was assessed using multinomial logistic regression analysis. Furthermore, among the 508 participants who participated in the follow-up survey two times or more, three patterns of the trajectory of psychological well-being were identified: heavily decreased group (n = 39), decreased group (n = 352), and increased group (n = 39). "Walking" as a coping behavior had a significantly higher odds ratio (OR) to be in the increased group (OR = 2.32, 95 % confidence interval (CI) 1.06-5.05, p = 0.035) compared to the heavily decreased group. "Conversations with family living together" had a slightly higher OR to become an increased group (OR = 1.96, 95 % CI: 0.87-4.41, p = 0.106), and "actively gathering information on COVID-19" had a slightly lower OR to become the decreased group (OR = 0.53, 95 % CI: 0.26-1.06, p = 0.072) compared to the heavily decreased group. The results of this study suggest how maintaining health in the early stage of the pandemic had a great influence on the long-term health status.

Association of social disengagement with health status and all-cause mortality among community-dwelling older adults: evidence from the Otassha study

This study examined the impact of disengagement on health status and mortality among community-dwelling older adults in Japan. Disengagement from society was operationally defined as dropping out of a longitudinal survey. A follow-up mail survey was conducted, in 2014, among respondents (n = 3696) of the baseline mail survey. Step-by-step follow-up surveys (FLs), including simplified mail, postcard, and home-visit surveys, were sent to participants who did not respond. Disengagement levels were defined according to the response to the FLs as zero (mail survey), low (simplified mail survey), middle (postcard survey), high (home-visit survey), and highest (non-responders to the home-visit survey). After adjusting for health status at baseline, the proportion of respondents self-rated as "not healthy" during FLs was significantly higher in the high-level than in the zero-level group. The proportion of respondents reporting a "once a week or less" frequency of going outdoors during FLs was significantly higher in the low-, middle-, and high-level groups than in the zero-level group. Mortality rates were significantly higher in the high and highest levels than in the zero-level group. Higher disengagement levels increased the risk of lower health status and mortality, suggesting an urgent need to prevent societal disengagement among older adults.

Determinants of new participation in sports groups among community-dwelling older adults: Analysis of a prospective cohort from The Otassha Study

Participation in sports groups has health benefits for older adults, such as preventing functional limitations and social isolation. Encouraging participation in sports groups may be an important means of health promotion in older adults. However, there is insufficient research on the determinants of new participation in sports groups to consider effective interventions to promote participation in these groups. We investigated this using data from a 1-year prospective study. Data were obtained from "The Otassha Study" that assessed a cohort of community-dwelling older adults living in an urban area of Japan. Of 769 older adults who participated in a baseline health survey in 2018, 557 participated in a follow-up survey in 2019. We excluded 184 individuals who already participated in sports groups at baseline and 36 with missing data. Participation in sports groups was defined as that occurring more than once a week. Logistic regression analysis was used to identify the determinants of new participation in sports groups, with sociodemographic factors, lifestyle habits, physical functions, cognitive functions, psychological factors, and social factors as independent variables. Forty-one (12.2%) individuals participated in sports groups at follow-up. In the multiple adjusted logistic regression model, new participation in sports groups was significantly associated with female sex (odds ratio [OR] = 5.57, 95% confidence interval [CI]: 1.61‒19.26), engagement in regular exercise (OR = 2.23, 95%CI: 1.03‒4.84), and having a large social network (OR = 1.12, 95%CI: 1.04‒1.20). Physical functions were not associated with new participation. Determinants of new participation were lifestyle habits and social factors, rather than physical functions. Intervention through social networks may be effective in encouraging new participation in sports groups, which, in turn, may facilitate healthy aging.

[Association between issues in activities and psychosocial health status in the social positions of older residents' community-based activities: a cross-sectional study]

Objectives　When local governments and community nurses provide support for community-based activities led by older residents, it is imperative to reduce the burden of participants in leadership positions. This study aimed to identify the issues associated with the activities by social position, such as leadership, support, and regular participation, to discuss effective support for community-based activities and to examine the association between social position, relating issues, and psychosocial health.Methods　Participants in community-based activities were recruited by the local government in Tokyo, Japan. Overall, 2,367 people from 155 activity groups from 40 municipalities responded. Social positions in the groups were defined as leaders who manage activities; supporters who support leaders; and regular members who do not have any specific role. The participants chose the issues of community-based activities from 10 items. Psychosocial health was measured by the WHO-5 well-being index (WHO-5) and Lubben social network scale-6 (LSNS-6). The relationship between recognition of issues and social positions were examined by the chi-square test. Interaction effects of social positions and issues (with or without) on the WHO-5 and LSNS-6 were investigated using a two-way analysis of covariance.Results　The final sample comprised 2,096 respondents: 174 leaders, 296 supporters, and 1,626 regular members. There was a significant association between recognition of social positions and issues in the groups: respondents who reported no issues in the activities comprised 8.6% of the leaders, 27.7% of the supporters, and 53.6% of the regular members (P<0.001). There was a large difference in recognition between roles for issues related to group management, such as the lack of management members. There was no significant interaction between these issues and social positions in either WHO-5 or LSNS-6 (P=0.729, P=0.171, respectively). The main effect of the social positions was significant in both analyses (P<0.001). The leaders and supporters showed significantly higher WHO-5 and LSNS-6 scores than regular members.Conclusion　The issues that the participants reported differed by social positions in activities. It may be effective to provide support according to the difficulty of sharing issues within the group. Regardless of whether or not the participants report issues, leaders and supporters had improved psychosocial health than regular members. The study concludes that organizational position in community-based activities may offer health benefits for older adults.

Comparison of Characteristics of Definition Criteria for Respiratory Sarcopenia—The Otassya Study

We compared the definitions of respiratory sarcopenia obtained from a model based on forced vital capacity (FVC) and whole-body sarcopenia, as recommended by the Japanese Association of Rehabilitation Nutrition (JARN), and a model based on the peak expiratory flow rate (PEFR), as recommended in our previous study. A total of 554 community-dwelling older people without airway obstruction who participated in our study in 2017 were included in the current study. Respiratory function, sarcopenia, and frailty were assessed. Pearson’s correlation coefficients of the associations of the FVC and PEFR with physical performance and the receiver operating curves of FVC and PEFR’s association with sarcopenia, long-term care insurance (LTCI) certification, and frailty were calculated. The sensitivity and specificity of the two respiratory sarcopenia models were assessed. The FVC and PEFR were associated significantly with physical performance. The areas under the curve for sarcopenia and the LTCI certification in the FVC and PEFR groups were statistically significant in both sexes. While Kera’s model had a lower specificity in determining sarcopenia, it had a sensitivity higher than the JARN model. Both models provide suitable definitions of respiratory sarcopenia. Future studies are required to determine other appropriate variables to define respiratory sarcopenia.

Exercise as a coping strategy and its impact on the psychological well-being of Japanese community-dwelling older adults during the COVID-19 pandemic: A longitudinal study

This study aimed to examine the prevalence of exercise as a coping strategy among Japanese community-dwelling older adults and its impact on their psychological well-being during the COVID-19 pandemic. In October 2019 (baseline [BL]), 720 community-dwelling older adults living in an urban area in Japan participated in a comprehensive health survey. Of these, 618 responded to a mail survey (follow-up [FL]) in June 2020, after the first state of emergency was lifted. Their psychological well-being was assessed using the WHO-5 Well-Being Index (WHO-5). Exercise as a coping strategy during the stay-at-home period was determined at FL by asking respondents whether they had engaged in 1) walking and 2) at-home exercise and strength training to maintain their physical and mental health. Each type of exercise's impact and the effective exercise combinations were examined. Time and group interaction effects on the WHO-5 scores were investigated using a two-way analysis of covariance. Of the final sample, 65.1% engaged in walking. The WHO-5 mean scores at BL and FL were 16.7 and 15.4 for the walking group and 16.7 and 14.5 for the non-walking group, respectively; interaction for time and group was significant. Additionally, 56.4% of the participants engaged home training. The WHO-5 mean score at BL and FL were 17.5 and 15.5 for the home training group and 15.7 and 14.5 for the no home training group, respectively; there was no significant interaction. Older adults who engaged in both walking and home training received higher score on the WHO-5 than those who engaged in only one activity at FL. The decline in psychological well-being was most attenuated in the walking only group compared to the at-home exercise and strength training groups. Exercise as a coping strategy during the stay-at-home period was associated with psychological well-being, with different impacts observed depending on the type of activity.

[Factors associated with participation in community activities after receiving long-term care preventive services]

Objectives　Since amending the long-term care insurance system to cover community-based services in 2015, community activities led by older residents have become increasingly important in Japan. It is necessary for local governments to effectively promote participation in community activities during long-term care prevention services. This study aimed to identify the factors associated with participation in community activities and the contents of intervention after long-term care prevention services in which interventions were conducted to promote older residents' participation in community activities.Methods　A secondary analysis of data collected in two classes of long-term care preventive services of a local government in Tokyo was conducted. This service provided not only interventions to improve physical function but also initiatives to promote participation in community activities after the service, such as learning and group-work activities. We analyzed participants' responses to self-administered questionnaires in 2016 and 2017; three months after the service started (T1) and six months after the service ended (T2). A total of 216 people (51 men and 165 women; age range: 65-95 years) responded to the questionnaires. Types of intervention, self-rated health, responses to the Kihon Checklist, and social capital, which was measured through items such as "Interaction with neighbors (SC1)," "Participation in groups other than preventive activity (SC2)," "Strength of trust for neighbors (SC3)," and "Mutual trust with neighbors (SC4)," were assessed at T1. Engaging in community activities was assessed to determine whether they participated in the self-motivating group for preventive activity at T2. Logistic regression analyses were conducted to examine the factors associated with participation in community activities by adjusting for each variable.Results　Totally, 113 respondents participated in community activities (participation rate=52.3%), and 103 did not participate (47.7%). Univariate logistic regression analyses revealed that types of intervention was significantly associated with participation in community activities (OR: 0.31, 95% CI: 0.15-0.63, P=0.001). Multivariate logistic regression models adjusted for all independent variables also indicated that types of intervention was significantly associated with participation in community activities (OR: 0.29, 95% CI: 0.14-0.62, P=0.001).Conclusion　The results showed that approximately 50% of the participants were involved in community activities because participation in such activities was promoted in long-term care preventive services. Types of intervention was a significant factor associated with participation in community activities. These findings highlight the importance of program contents in community activities during preventive services.

Change in subjective health status among frail older Japanese people owing to the coronavirus disease pandemic and characteristics of their responses

Aim

The coronavirus disease 2019 (COVID‐19) pandemic remains a major global public health issue, and it has led to restrictions in physical and social activities among community‐dwelling people, including frail older adults. This study aimed to determine the impact of the pandemic on the subjective health status and characteristics of community‐dwelling frail older adults by assessing their knowledge of infection, behaviors and negative psychological response.

Methods

During October 2019, 720 older adults participated in “The Otassha Study.” A year after the COVID‐19 outbreak, between June 29 and July 31, 2020, a health status questionnaire, comprising questions concerning knowledge about infection, behaviors and psychological responses during the pandemic, was sent to all participants of the health examination in 2019. Respondents were divided into the robust and frail groups, and their responses were compared.

Results

Although the self‐reported health status of the older adults in both groups was worse in 2020 than in 2019, differences were not observed in the degree of deterioration between the groups. Those in the frail group had fewer resources of information related to COVID‐19 and had fewer coping behaviors for health maintenance compared with the robust group.

Conclusion

Information gathering and actions aimed at health maintenance tended to be weaker among older adults with frailty, although the influence of COVID‐19 on subjective health status did not differ significantly between robust and frail adults. Therefore, robust and frail older adults may need to adopt different countermeasures to prevent worse health during this pandemic. Geriatr Gerontol Int 2021; 21: 1053–1059.

Change in outdoor walking behavior during the coronavirus disease pandemic in Japan: A longitudinal study

BACKGROUND

Due to the high infectivity and seriousness of coronavirus disease, people's daily activities were restricted in countries worldwide; governments implemented lockdown measures and advised individuals to perform self-restraint in terms of leaving the house. However, there have been few scientific reports on the effects of such behavioral restrictions on walking parameters.

RESEARCH QUESTION

Did behavioral restrictions during the state of emergency in Japan effect walking parameters in daily life outdoor walking?

METHODS

In this retrospective cohort study, four walking parameters, namely, the average number of steps taken, walking speed, step length, and cadence, were measured using a smartphone application among 3901 participants (mean age ± standard deviation: 60.3 ± 28.9 years) from March 2 to June 15 in both 2019 and 2020. Repeated-measures two-way analysis of variance was used to compare the walking parameters between the two years.

RESULTS

The number of steps significantly decreased (p < .001) in 2020 (∼3400 steps) compared to that in 2019 (∼4400 steps), indicating that the state of emergency greatly affected the amount of physical activity performed per individual. Conversely, walking speed increased (p < .001 during the period when the state of emergency was issued) in 2020 (∼1.25 m/s) compared to that in 2019 (∼1.23 m/s), attributable to an increased step length.

SIGNIFICANCE

Although changes in walking speed and step length were small compared to those in the number of steps, those changes were consistently seen during the state of emergency, suggesting that people tried to walk faster in their outdoor walking. Such change in walking behavior may have protected further deterioration of health due to restricted activity.

[Effectiveness of a program promoting community activities for the prevention of frailty using a community assessment]

AIM

We developed a program to promote community activities for preventing frailty using the Community-as-Partner model. We aimed to clarify whether or not participants' extent of practice relating to frailty prevention activities increased after the classroom, as well as the effectiveness of the program for preventing frailty.

METHODS

The participants were recruited from among pre-frailty and frailty individuals in a cohort study of community-dwelling older adults. Thirty-two participants completed the classroom intervention. Thereafter, every three months, through a telephone survey, the participants were asked about the extent of practice regarding their frailty prevention activities. The Kihon Checklist and Japanese version of the Cardiovascular Health Study (J-CHS) frailty index were surveyed as outcome measures during the cohort study conducted six months before the classroom (baseline [BL]) as well as approximately one year after this intervention (follow-up [FL]). The changes in the outcome measures between the BL and FL in the intervention group were compared to those in the control group matched by the propensity score.

RESULTS

The frailty prevention activities saw a maximum increase around six to nine months after the classroom. The J-CHS frailty index showed a group × time-of-survey significant interaction (F = 6.531, p=0.012) and significantly decreased from 1.3 at BL to 0.8 at FL in the intervention group (p=0.009).

CONCLUSIONS

The practice of activities relating to frailty prevention increased after the classroom, and the participants also showed improvements in their physical frailty. The present program seems likely to be effective preventing frailty.

[Effective support based on length of participation for community-based activities led by older residents]

Objectives　Community-based activities led by older residents are important in preventing long-term care and enhancing social participation among older persons in Japan. Local governments and community nurses are required to support these activities. However, there is no knowledge about the issues of residents who participate in community-based activities, which is essential for the effective support of community-based activities. We aimed to examine the association between the length of participation and recognized issues among community-based activities.Methods　Through the local governments in Tokyo, we recruited participants from community-based activity groups; 2,367 people from 155 activity groups from 40 municipalities responded. The presence or absence of 10 items of recognized issues, such as lack of management members and lack of teachers, were examined. The number of years of participation in the activity was divided into four groups: "less than 1 year," "more than 1 year and less than 2 years," "more than 2 years and less than 4 years," and "more than 4 years." Logistic regression analysis was conducted to examine the association between the length of participation and recognized issues.Results　The number of analyzed respondents was 2,194 (14.5% were male and the average age was 76.9 years). Compared to "less than 1 year" group, the "more than 2 years and less than 4 year" group recognized "aging of group" (OR=1.92), "lack of management members" (OR=1.61), and "health condition of participants" (OR=1.47) as issues. In the "more than 4 years" group, "aging of group" (OR=3.24), "lack of management members" (OR=2.63), "lack of participants" (OR=2.12), "health condition of participants" (OR=1.95), "mannerism of activities" (OR=1.62), and "lack of place" (OR=1.48) were recognized as issues.Conclusion　Issues recognized by participants in community-based activities differed depending on the number of years they had been participating in the activity. This suggests that it is necessary to provide appropriate support taking the length of participation into account. For example, the issue of the "health condition of participants" was recognized by participants who had been participating in the activity for approximately two years. Consequently, "lack of participants" may have occurred in participants who have been participating in the activity for four years. Therefore, promoting the health management of participants from the early phase of community-based activity would be effective in preventing dropout.

Association between activity diversity and frailty among community-dwelling older Japanese: A cross-sectional study

PURPOSE

Deterioration of daily activities increases frailty risk. Most of the previous research has examined the association between frailty and specific activities; nevertheless, the diversity of daily activities is also important. Although the type, frequency, and evenness of daily activities have been proposed as indicators of activity diversity, the association between these indicators and frailty remains unclear. In this study, we examined the association between activity diversity and frailty in community-dwelling older adults.

MATERIALS AND METHODS

This cross-sectional study comprised 658 community-dwelling older adults aged ≥ 65 years who participated in comprehensive health check-ups in 2018. Frailty was defined using the Japanese version of the Cardiovascular Health Study criteria. Three indicators, type, frequency, and evenness of daily activities, were used to assess activity diversity across one week. Multiple logistic regression analyses were performed, with frailty as the dependent variable and the three activity diversity indicators as independent variables. Socio-demographic, physical, and mental functioning factors were adjusted as covariates.

RESULTS

Of the 658 participants (median age: 72 years; age range: 65-91 years; 60.5% women), 27 (4.1%) met the criteria for frailty. The frail group had significantly lower scores for type, frequency, and evenness of daily activities, as well as Mini-Mental State Examination scores (all at p < 0.01). We found significant independent associations in all activity diversity indicators with frailty, in multiple logistic models.

CONCLUSION

Activity diversity is independently associated with frailty in community-dwelling older adults.

Factors associated with follow-up difficulty in longitudinal studies involving community-dwelling older adults

This study aims to clarify the factors associated with the gradual withdrawal from society in older adults. We defined the stages of follow-up difficulty based on four follow-up surveys on non-respondents of longitudinal mail surveys in community-dwelling older adults to examine the main factors associated with the stages of follow-up difficulty. We conducted a follow-up mail survey (FL1) with respondents of a baseline survey, and three more follow-up surveys with the non-respondents of each previous survey: simplified mail (FL2), postcard (FL3), and home visit surveys (FL4). The respondents of each follow-up survey were defined as a stage of follow-up difficulty; their characteristics concerning social participation and interaction at baseline in each stage were analyzed. The number of respondents in the FL1, FL2, FL3, and FL4 stages and non-respondents (NR) were as follows: 2,361; 462; 234; 84; and 101, respectively. Participation in hobby groups in FL2 and FL3, sports groups in FL4, and neighborhood association and social isolation in NR were significantly associated with the stage of follow-up difficulty. Based on these results, we conclude that the following factors are associated with each stage of follow-up difficulty: 1) a decline in instrumental activities of daily living in the FL2 and FL3 stages, 2) dislike for participating in physical activity such as sports in the FL4 stage, and 3) social isolation, not even belonging to a neighborhood association due to low social interaction in the NR group.

Social participation reduces isolation among Japanese older people in urban area: A 3-year longitudinal study

Objectives

Social isolation is a particular problem among older people and social participation may reduce future isolation. However, it is unclear which types of activities and which level of participation are effective. This study examines the relationship between social participation and isolation among Japanese older people by employing a 3-year longitudinal study.

Methods

A mail survey was sent to 3,518 community-dwelling older people in an urban area in 2014 (baseline: BL). We then conducted follow-up mail survey on respondents who were non-isolated at BL in 2017 (follow-up: FL), with isolation being defined as being in contact with others less than once a week. An analysis was carried out on 1,070 subjects (398 men and 672 women). Social participation is defined by participation in group activities (community, senior club, hobbies, sports, volunteering, politics, industry, and religion). A logistic regression analysis was conducted to determine the association between the types of social participation and the number of organization types at BL, and isolation at FL.

Results

At FL, 75 men (18.8%) and 59 women (8.8%) were considered to be isolated. Among the men, participation in a hobby group and sports group both significantly reduced the degree of isolation. Moreover, participation in two organizations and three or more organizations significantly lowered the risk of isolation when compared to non-participants. Among women, there were no significant associations among particular types of social activities and isolation. On the other hand, participation in one organization and three or more organizations significantly reduced their isolation when compared to non-participants. There was a significant linear trend between the number of types of organizations and isolation, regardless of gender.

Conclusions

Participation in social activities reduces future isolation in older people. Encouraging participation in social activities could help reduce negative health outcomes associated with social isolation later in life.

[Predictors of social isolation among older people living in urban area: a prospective study]

Objectives　We aimed to investigate the predictors of social isolation among older people living in urban area.Methods　A mail survey was sent out to 7,015 elderly subjects living in nine districts of Itabashi ward. At baseline (2012), 3,696 subjects and at follow-up (2014) 2,375 replied to the self-administered questionnaire. We defined social isolation as seeing friends or relatives less than two or three times a month. Gender, age, self-rated health, present illnesses, instrumental activities of daily living (IADL), frequency of going out, frequency of social participation, family structure, and perceived financial status were also investigated. A t-test, a chi-square test, and logistic regression analysis were conducted to examine the predictors of social isolation in a follow-up study.Results　Of the 1,791 subjects who were analyzed for social isolation, 348 (19.4%) were found to be socially isolated in 2014. A multiple logistic regression analysis showed that men (adjusted odds ratio, 1.88; 95% confidence interval, 1.41-2.50) were significantly more likely to be isolated than women. Being older (1.03, 1.01-1.06) was also a significant predictor of isolation. Subjects who participated in group activities one to three times a month (1.62, 1.04-2.53) were significantly more likely to be isolated than those who participated in them more than once a week. Subjects who rated their financial status as low (1.67, 1.20-2.32) were more likely to be isolated than those who rated it as high. Subjects who were isolated (10.24, 7.60-13.81), and those who did not respond to questions about isolation (8.15, 3.76-17.67), were significantly more likely to be isolated than those who were not isolated at baseline. Among the subjects who were not isolated at baseline, being male (2.39, 1.57-3.64) and lower self-rated health (3.99, 1.33-11.94) were predictors of social isolation.Conclusion　Participation in social activities is effective in preventing social isolation among elderly men living in urban area.

Methylprednisolone reduces postoperative nausea in total knee and hip arthroplasty

WHAT IS KNOWN AND OBJECTIVE

Total knee and hip joint replacement has a high risk of postoperative nausea and vomiting (PONV), and steroid cover is used for cases associated with autoimmune diseases. Our aim is to evaluate the antiemetic efficacy of methylprednisolone as steroid cover in patients undergoing the surgery.

METHODS

A prospective cohort study design was used. Sixty-eight patients, aged between 20 and 80 years, were scheduled for a standardized general anaesthetic technique. Patients who were given methylprednisolone were assigned as the steroid cover group, and those who were not given methylprednisolone formed the non-steroid cover group. PONV were assessment by direct questioning or spontaneous complaints by patients 1 week after surgery. Postoperative pain was evaluated using Visual Analog Scale (VAS) 1 and 3 days after surgery.

RESULTS AND DISCUSSION

The incidence of nausea in the steroid cover group was significantly less than that in the non-steroid cover group (adjusted odds ratio, 0·17, P = 0·021), but there was no significant difference in vomiting between the two groups. Postoperative pain VAS score was not significantly different between groups.

WHAT IS NEW AND CONCLUSION

In total knee and hip arthroplasty, methylprednisolone is effective in preventing postoperative nausea; however, higher doses of methylprednisolone may be needed to prevent vomiting.

Shape-memory alloy loop snare for endoscopic photodynamic therapy of early gastric cancer

BACKGROUND AND STUDY AIMS

Photodynamic therapy (PDT) has proved effective in the treatment of gastric cancer, but there is room for improvement. To achieve the technical goal of carrying out endoscopic PDT, endoscopists need to determine the precise area for laser irradiation at adequate dosages. This report describes the use of a shapememory alloy (SMA) loop snare as a useful tool in endoscopic PDT.

PATIENTS AND METHODS

Eleven patients with biopsy-proved early gastric cancer were treated with endoscopic PDT after intravenous injection of Photofrin II (2 mg/kg b.w.). Five patients underwent PDT using the SMA loop snare, and six underwent PDT without the use of the device. Cancer lesions smaller than 2 cm in diameter were irradiated with an excimer-dye laser (4 mJ, 80 Hz, 630 nm) for 20 min.

RESULTS

All five patients (100%) treated with PDT using the SMA loop snare, and four of the six patients (67%) treated with PDT without use of the SMA loop snare, showed complete remission.

CONCLUSIONS

The SMA loop snare routinely forms a circle 2 cm in diameter, covering an area of 3.14 cm2, and makes it possible to mark and calculate the precise area of cancerous lesions for irradiation at appropriate dosages. The findings of this study suggest that the SMA loop snare is an effective tool for PDT in early gastric cancer.

The frequencies of diabetic complications in elderly non-insulin dependent diabetic patients in Himeji

Data on 746 patients with non-insulin-dependent diabetes mellitus (NIDDM) were collected from the Internal Medical Association in Himeji by questionnaire, and the patients were divided into six groups according to the duration of illness. Frequencies of various complications according to the duration of illness and risk factors of complications were compared between men and women. Although the number of male patients was 417, significantly more than the 329 female patients, many female patients were elderly, and the age at initial onset was about 10 years older than that of the male patients. Fasting blood sugar and hemoglobin A1c levels increased with the duration of illness. The female patients showed a greater tendency to suffer from hypertension, hyperlipidemia and obesity than the male patients. There was positive correlation between the incidence of complications and duration of illness. This tendency was more marked in the female patients than in the male patients. Both male and female patients showed a tendency for microangiopathy to appear earlier than macroangiopathy. The increase in the frequency of complications accompanying the increase in the duration of illness was more marked for microangiopathy than for macroangiopathy.

Clinical effects of long-term administration of pimobendan in patients with moderate congestive heart failure

The long-term efficacy of the positive inotropic and vasodilator drug, pimobendan, was assessed in 21 patients suffering from symptomatic heart failure. Patients were randomized to 16 weeks of double-blind therapy with either 2.5 or 5.0 mg/day of pimobendan (n = 10), or a matching placebo (n = 11). Patients were blinded on the study drug if their clinical status had not substantially worsened during the study. Of the placebo-treated patients, 5 patients were withdrawn from the study because of a deterioration of their heart failure, while none of the active treated group was withdrawn because of increased symptoms. Quality of life, assessed by the specific activity scale derived from the metabolic costs of individual physical activity, was 3.45 +/- 0.90 (SD) mets in the baseline state and increased significantly after week 16, averaging 5.07 +/- 1.40 and 4.67 +/- 1.47 mets at weeks 16 and 24, respectively. In the placebo-treated group, the specific activity scale was 3.27 +/- 1.21 mets at the baseline and remained unchanged throughout the study period. Patients treated with pimobendan were able to significantly increase their exercise duration. The accompanying increase in peak oxygen uptake was statistically insignificant, due to the limited number of patients enrolled in the study. These results suggest that in contrast to the recent pessimistic view of the long-term efficacy of cardiotonic drugs, pimobendan is beneficial in treating patients with congestive heart failure and may favorably modify their prognosis. Further large-scale evaluation of this agent is warranted.

Determinants of beneficial effect of heparin exercise treatment on treadmill capacity and long-term efficacy of the therapy in patients with chronic effort angina

The purpose of the present study was to evaluate the factors which influence the effect of heparin exercise treatment on treadmill capacity, and to examine the long-term efficacy of the treatment in 16 patients with chronic effort angina. Treadmill exercise was performed 20 times for 2 to 3 weeks according to standard Bruce protocol. A single intravenous dose of heparin (5,000 IU) was given 10 min before each exercise period. Exercise with heparin pretreatment increased the total exercise duration from 6.6 +/- 1.6 (SD) to 9.4 +/- 1.9 min (p < 0.05) and the maximal rate-pressure product from 19,200 +/- 4,700 to 24,700 +/- 5,900 mmHg.beats/min (p < 0.05). The rate-pressure product at the onset of angina was also increased by 32% (p < 0.05). The ST segment depression at the same exercise time as in control exercise was ameliorated from 0.16 +/- 0.05 to 0.12 +/- 0.06 mV (p < 0.05). Multivariate analysis of the determinants of the effect of the treatment on treadmill capacity indicated that the treatment is more effective in patients without previous myocardial infarction. All of the above-mentioned variables of treadmill capacity did not change significantly during a follow-up period of 13 +/- 7 months (range; 4-24 months). These findings lend further support to heparin exercise treatment as a possible therapeutic approach in patients with chronic stable effort angina, and particularly in those without previous infarction.

Importance of non-stenosed donor coronary arteries for collateral flow reserve

To elucidate whether the presence of significant stenoses in donor coronary arteries compromises collateral flow reserve, coronary arteriography was performed in 22 patients with stable effort angina who had a complete obstruction in one of the major coronary arteries. The patients were divided into two groups according to the absence (group I: n = 11) or presence (group II: n = 11) of significant stenoses (> or = 75% stenosis of the luminal diameter) in donor arteries. After conventional cardiac catheterization, coronary arteriography was repeated before and during rapid atrial pacing. Coronary collateral circulation was evaluated by means of angiographic contrast appearance time (CAT) which was defined as the time (s) until the epicardial segments distal to the site of complete occlusion were opacified after the injection of contrast medium into the donor artery. The pressure gradient across the collateral circulation (mean aortic pressure minus left ventricular end-diastolic pressure) remained unchanged before and during rapid atrial pacing (group I: 95 +/- 14 vs. 99 +/- 15 mmHg; group II: 91 +/- 18 vs. 94 +/- 16 mmHg). Rapid atrial pacing decreased the contrast appearance time in group I from 1.73 +/- 0.34 to 1.47 +/- 0.37 s (P < 0.01), but was not changed in group II from 1.68 +/- 0.36 to 1.73 +/- 0.51 s (P = n.s.). It was concluded that coronary collateral circulation is further augmented in response to an increase in myocardial oxygen demand in patients with non-stenosed donor coronary arteries and significant stenoses in donor arteries compromise an increase in collateral blood flow.

Adult respiratory distress syndrome in a patient with uncomplicated acute myocardial infarction

A 53-year-old woman was admitted with a diagnosis of acute extensive anterior myocardial infarction. Pulmonary capillary wedge pressure was 17 mmHg, and cardiac index 2.4 l/min.m2. The patient was successfully treated with diuretics and nitrates but on the fifth hospital day moist rales were noted over the entire lung field. A chest roentgenogram showed diffuse bilateral pulmonary infiltration with unchanged cardiac silhouette. Arterial oxygen partial pressure was reduced to 45 mmHg under 3 liters of nasal oxygen inhalation. Pulmonary capillary wedge pressure was 8 mmHg. Diffuse infiltration was not ameliorated by intravenous injection of diuretics. The diagnosis of adult respiratory distress syndrome was finally established by successful treatment with steroids.

The sensitivity of intracoronary injection of acetylcholine in inducing coronary spasm differs in patients with stable and unstable angina

In an attempt to clarify the role of coronary artery spasm in the pathogenesis of unstable angina, acetylcholine (20 and 50 micrograms) was injected directly into the coronary arteries of 19 patients with unstable effort angina (group 1), 30 patients with unstable spontaneous angina (group 2), and 15 patients with stable effort angina due to coronary artery organic stenosis (greater than or equal to 75%) (group 3). Coronary spasm was defined as severe vasoconstriction (greater than or equal to 90% of luminal diameter) with chest pain and/or ischemic ST-segment changes. Intracoronary injection of acetylcholine induced spasm of at least one coronary artery in 19 patients (100%) of group 1 and 28 (93%) of group 2 but only 3 (20%) of group 3 (p less than 0.01). When acetylcholine was injected into the left and right coronary arteries separately, multivessel spasm (spasm of both coronary arteries) was induced in 5 of 12 (42%) patients of group 1 and in 9 of 23 (39%) patients of group 2. In contrast, intracoronary acetylcholine did not cause multivessel coronary spasm in any of 15 patients of group 3 (0%). These results suggest that coronary arteries in patients with unstable effort angina as well as spontaneous angina are susceptible to spasm and that coronary artery spasm may be responsible at least in part for the genesis of attacks in these patients.

Relationship between the preexistent coronary collateral circulation and successful intracoronary thrombolysis for acute myocardial infarction

The purpose of this study was to evaluate whether the existence of coronary collateral circulation influences recanalization rates of intracoronary thrombolysis. The study population consisted of 85 consecutive patients undergoing intracoronary thrombolysis within 6 hours after the onset of the first acute myocardial infarction, all of whom had a complete occlusion of the infarct-related coronary artery. Intracoronary thrombolysis with high-dose urokinase (960,000 IU) was attempted at a rate of 24,000 IU/min. Of 18 patients (group A) who had good angiographic collateral circulation to the area perfused by the infarct-related coronary artery, the obstructed artery was recanalized to a residual luminal diameter stenosis of less than or equal to 90% (successful recanalization) in only five (28%). In contrast, of 67 patients (group B) with poor or no collateral circulation, recanalization was successful in 40 (60%) (p less than 0.05). Antegrade flow of infarct-related arteries was observed following thrombolysis in 12 (67%) of 18 group A patients and in 56 (84%) of 67 group B patients (p = NS). It was concluded that (1) the presence of collaterals correlates with the presence of high-grade stenosis; (2) the presence of collaterals correlates with the presence of high-grade stenosis; (2) the presence of collaterals is inversely related to the efficacy of thrombolytic therapy; and (3) the difference in successful recanalization rates observed between the two groups probably reflects the impact of underlying stenosis severity on the effectiveness of lytic therapy.

Biphasic changes (initial increase and late decrease) in coronary sinus venous oxygen saturation during anginal attacks induced by intracoronary acetylcholine in patients with variant angina

In order to evaluate the effects of intracoronary acetylcholine on coronary resistance vessels, oxygen saturation in coronary sinus blood was continuously measured to compare its dynamic changes during intracoronary injection of acetylcholine in both patients with variant angina and control subjects. Group 1 consisted of 6 patients without coronary artery disease. Group 2 consisted of 10 patients with variant angina and spasm in the left anterior descending coronary artery. A fiberoptic reflection oximetry system was used for the continuous measurement of coronary sinus venous oxygen saturation. Acetylcholine (20 micrograms) was injected directly into the left coronary artery over 30 s. In the group 1 patients, coronary sinus venous oxygen saturation was increased from 39 +/- 2% (mean +/- SEM) to 54 +/- 3% at 30 s, continuously climbed to 70 +/- 3% at 60 s and then gradually decreased to 53 +/- 5% at 120 s after the initiation of intracoronary injection of acetylcholine. In contrast, in the group 2 patients, coronary sinus venous oxygen saturation was transiently increased from 39 +/- 2% to 56 +/- 4% at 30 s, reversed, decreased to 52 +/- 4% at 60 s and then rapidly decreased to 36 +/- 3% at 120 s with the onset of chest pain associated with electrocardiographic ischemic changes. Coronary arteriography during attacks demonstrated a total or subtotal occlusion of the left anterior descending coronary artery due to severe spasm in all of the 10 patients. The extent of increases in coronary sinus venous oxygen saturation at 30 s after acetylcholine injection was not significantly different between the two groups (group 1: 15 +/- 4%, group 2: 17 +/- 3%). Heart rate, blood pressure and rate-pressure product were essentially unchanged at 30 s after intracoronary injection of acetylcholine in both groups. These data suggest that in control adult humans, coronary blood flow was increased through dilatation of resistance vessels by acetylcholine, while in patients with variant angina, coronary blood flow was transiently increased by dilatation of resistance vessels, after which it was suddenly decreased by spasm of an epicardial artery induced by this agent. Relaxant responses to acetylcholine of coronary resistance vessels appear to be preserved well in patients with variant angina.

Usefulness of intracoronary injection of acetylcholine as a provocative test for coronary artery spasm in patients with vasospastic angina

In order to examine both the sensitivity and specificity of coronary artery spasm induced by intracoronary injection of acetylcholine in patients with vasospastic angina, incremental doses of acetylcholine (20, 30, and 50 micrograms) were injected directly into each coronary artery in 21 patients with variant angina (group A), in 28 patients with other types of vasospastic angina (group B), and in 20 patients without any significant coronary artery disease (group C). Coronary artery spasm was defined as severe vasoconstriction (greater than or equal to 90% of reduction in luminal diameter) with chest pain and/or ischemic changes in the electrocardiogram. Intracoronary injection of acetylcholine induced spasm of at least one coronary artery in 20 patients (95%) of group A, in 27 patients (96%) of group B, and in only 2 patients (10%) of group C. The low dose of acetylcholine (20 micrograms) induced coronary spasm more frequently in group A patients (81%) than in group B patients (43%) (P less than 0.05). ST-segment elevation associated with anginal attacks was significantly (P less than 0.05) more frequent in group A (71%) than in group B (39%). When acetylcholine was injected separately into the left and right coronary arteries, spasm of both coronary arteries was observed in 7 out of 14 of group A (50%), in 8 out of 22 of group B (36%), and in none of the 20 of group C. We concluded that intracoronary injection of acetylcholine is a sensitive and reliable method for the induction of coronary spasm in patients with vasospastic angina as well as in those with variant angina.

Importance of coronary collateral circulation for increased treadmill exercise capacity by nitrates in patients with stable effort angina pectoris

The purpose of this study was to elucidate the mechanism that induces an improvement in exercise capacity by nitrates in patients with stable effort angina pectoris. The study population was composed of 19 patients: group A, 10 patients with chronic stable effort angina who had a well-developed coronary collateral circulation to the potentially ischemic region; group B, 9 patients with chronic stable effort angina who had no collateral circulation to the jeopardized myocardium. Treadmill exercise was performed according to the standard Bruce protocol with and without pretreatment with orally administered 10 mg isosorbide dinitrate. Percent increases (mean +/- SE) in exercise duration were not significantly different between groups A and B (25 +/- 6 vs. 14 +/- 6%). Percent increases in the maximal rate-pressure product tended to be greater in group A than in group B (27 +/- 6 vs. 10 +/- 6%). Percent increases in the rate-pressure product at the onset of angina pectoris were significantly greater in group A than in group B (37 +/- 7 vs. 7 +/- 6%; p less than 0.01). Percent increases in the rate-pressure product at 0.1 mV S-T segment depression were also significantly greater in group A than in group B (26 +/- 6 vs. 1 +/- 5%; p less than 0.01). These results suggest that isosorbide dinitrate dilates epicardial collateral vessels with smooth muscle layers, but fails to dilate the coronary arteries with significant organic stenoses.

Photodynamic therapy for early gastric cancer using a pulsed gold vapor laser

Endoscopic photodynamic therapy (PDT) using a pulsed gold vapor laser (wavelength 628 nm, LaserSonics Inc.) was performed on eight cases of early gastric cancer. Three patients refused to have surgery, and the others were in a high-risk group due to old age or complications with other diseases. Hematoporphyrin derivative (HpD I, 2.5-3 mg/kg, Photofrin Inc.) was injected intravenously, and 48-72 hours later, the entire cancer lesion and 5 mm width mucosa encircling it were irradiated with a gold vapor laser through a single quartz fiber. The irradiation was delivered at 300-330 mW for 5-20 minutes, which gave about 90 J/cm 2 dosage. In seven of eight cases, local cure was achieved. Recurrence was noted only in one patient. In one of eight patients, operation was carried out 1 month after PDT. Pathological examination of the resected stomach revealed that the effect of PDT extended into the tunica muscularis propria. Side effects of HpD, such as skin rash, were noted in two patients, but no serious complications of PDT were encountered. This suggests that PDT with a pulsed gold vapor laser is clinically useful in the treatment of early gastric cancer.

Comparative sensitivity of intracoronary injection of acetylcholine for the induction of coronary spasm in patients with various types of angina pectoris

To elucidate the possible contribution of coronary artery spasm to the pathogenesis of angina pectoris, coronary arterial responses to intracoronary injection of acetylcholine were examined in patients with various types of angina pectoris. Coronary artery spasm with chest pain and/or electrocardiographic ischemic changes was angiographically demonstrated in 50 (85%) of 59 patients with angina pectoris. The sensitivity for coronary spasm was 92% (24 of 26) in patients with rest angina, 100% (16 of 16) in patients with both rest and effort angina, and 59% (10 of 17) in patients with effort angina, while it was only 6% (1 of 16) in patients without coronary artery disease. When patients with effort angina were subdivided according to the variability of anginal threshold for exertional angina, the sensitivity for coronary spasm was as high as 90% (9 out of 10) in patients with variable-threshold angina. In contrast, coronary spasm was less frequently (p less than 0.05) induced in patients with fixed-threshold angina (1 of 7, 14%). These results suggest that coronary arteries in patients with angina pectoris are quite susceptible to acetylcholine except in those patients with stable exercise tolerance or anginal threshold. Thus coronary artery spasm appears to play a significant role for the pathogenesis of angina pectoris in a large proportion of patients with effort angina as well as in patients with rest angina.

Significance of collateral circulation in reversible left ventricular asynergy by nitroglycerin in patients with relatively recent myocardial infarction

To evaluate the functional role of coronary collateral circulation in reversible asynergy of the left ventricle, cineventriculography was performed before and after the administration of sublingual nitroglycerin in 19 patients with complete occlusion of the proximal part of the left anterior descending coronary artery. In nine patients who had significant collateral circulation to the infarct-related coronary artery (group A), there was significant improvement in both the left ventricular ejection fraction (53% to 60%, p less than 0.05) and regional wall motion in the infarct zone (8% to 18%, p less than 0.01 in the anterolateral area) with administration of nitroglycerin. In contrast, in the remaining 10 patients without significant collateral perfusion (group B), there were no detectable changes in either global function (49% versus 50%) or regional wall motion (6% versus 8% in the anterolateral area) before and after nitroglycerin. Changes in heart rate and left ventricular peak systolic and end-diastolic pressures with nitroglycerin were comparable in both groups. These results suggest that angiographically demonstrable collaterals preserve viable myocardium, which can improve its contraction when the supply-demand relationship is favorably affected because of increased collateral flow and/or more favorable loading conditions produced by nitroglycerin.

Effects of heparin treatment on collateral development and regional myocardial function in acute myocardial infarction

To define the effects of heparin treatment during the acute stage of the first anterior myocardial infarction on coronary collateral development and regional myocardial function, we evaluated angiographically the extent of a collateral visualization (collateral index: 0-3) to the completely obstructed infarct-related coronary artery and regional wall motion in 18 patients during convalescence after infarction. The patients were divided into two groups depending on the presence (group I) or absence (group II) of heparin treatment (170 to 220 IU/kg per day) during the acute phase of infarction. The collateral index was significantly higher in group I (1.5 +/- 0.9) than in group II (0.4 +/- 0.4; p less than 0.05). The left ventricular ejection fraction tended to be greater in group I than in group II (49 +/- 12% vs 38 +/- 16%), and there was a significant difference in regional wall motion of the infarct area that was evaluated by the percentage of segment shortening between the two groups (group I:7.4 +/- 9.2%, group II:-0.8 +/- 4.5%, p less than 0.05). These findings indicate that heparin treatment for patients with acute myocardial infarction is worthwhile in terms of the preservation of left ventricular function as a result collateral development.

[Induction of coronary arterial spasm by intracoronary administration of acetylcholine in patients with vasospastic angina]

To examine whether intracoronary injections of acetylcholine induce coronary artery spasm in patients with vasospastic angina, incremental doses (20, 30 and 50 micrograms) were injected directly into the coronary arteries in 12 patients with variant angina (Group A: rest angina with electrocardiographic ST-segment elevation during attacks), 19 with vasospastic angina (Group B: rest angina and/or effort angina with variable threshold in the treadmill exercise stress test), 11 with organic coronary artery stenosis but without angina (Group C), and 14 without coronary artery disease (Group D). A temporary cardiac pacemaker was positioned in the right ventricle. Coronary artery spasm was defined as severe vasoconstriction (greater than or equal to 90% of reduction in the luminal diameter) with chest pain and/or ischemic changes in the electrocardiogram. Intracoronary injection of acetylcholine induced spasm of at least one coronary artery in all 12 patients (100%) of Group A, in 18 (95%) of Group B, in two (18%) of Group C, and in two (14%) of Group D. Thus, the sensitivity of this method for inducing coronary spasm was 100% in group A, 95% in Group B, and 97% in Group A plus Group B. The specificity for inducing spasm was 86% in Group D, and 84% in Group C and Group D. When acetylcholine was injected separately into the left and right coronary arteries, spasm of both the coronary arteries was observed in two (40%) of Group A, in five (33%) of Group B, and none (0%) of Group C and Group D. Acetylcholine (20 micrograms) induced coronary spasm in 10 (83%) of Group A and only in nine (47%) of Group B.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary collateral development after acute myocardial infarction

In 31 patients without a history of preinfarction angina, coronary collateral circulation to the completely obstructed coronary artery was evaluated by coronary angiography during a convalescent period of their first myocardial infarction. Collateral visualization (collateral index) was found to be significantly greater in patients with involvement of the right coronary artery (2.1 +/- 1.1, SD) than in those with obstruction of the left anterior descending coronary artery (1.2 +/- 1.0, p less than 0.05). The time interval from the onset of symptoms of acute myocardial infarction to angiographic evaluation did not affect the extent of collateral visualization or the degree of coronary artery disease. These findings indicate that the collateral vessels develop after acute myocardial infarction regardless of the extent of coronary artery disease and accomplish the proliferative process within one month. It is also suggested that the collateral visualization is dependent on the size of perfusion territory of the infarct-related coronary artery.

Importance of regurgitant fraction for left ventricular end-systolic wall stress to end-systolic volume ratio in patients with chronic mitral regurgitation

End-systolic wall stress to end-systolic volume index (ESWS/ESVI) ratio is an index of myocardial contractility. In the presence of mitral regurgitation (MR), this ratio may be modified by the unloading effect of a leakage of flow into the low pressure left atrium. Therefore, to evaluate whether or not this ratio is an index of myocardial function in patients with MR, we compared the ratio with conventional measurements of myocardial performance in 11 patients with moderate to severe MR. The ESWS/ESVI ratio was 3.9 +/- 1.6 kdyn/cm5 per m2 in MR and slightly lower than the control value of 4.6 +/- 0.6 kdyn/cm5 per m2. The correlation between ESWS/ESVI ratio and ejection fraction was poor (r = 0.05, p:NS), while there was a close inverse correlation between the ratio and regurgitant fraction (r = 0.76, p less than 0.01). These results strongly suggest that ESWS/ESVI ratio is a better indicator of myocardial function than ejection fraction in MR; however, this ratio could be affected by not only the inotropic state of the ventricle, but also by the extent of mitral regurgitation.

Space Experiments with Particle Accelerators

Electron and plasma beams and neutral gas plumes were injected into the space environment by instruments on Spacelab 1, and various diagnostic measurements including television camera observations were performed. The results yield information on vehicle charging and neutralization, beam-plasma interactions, and ionization enhancement by neutral beam injection.