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Aim: Caregivers in home care settings may experience significant physical, emotional, and financial burdens in providing toileting assistance. However, few studies have evaluated these three aspects of caregiver burden. Therefore, this study aimed to clarify the physical, emotional, and financial burdens of toileting assistance and examine the factors associated with each burden. Methods: A self‐administered postal questionnaire was distributed to 405 family caregivers of older adults receiving home care and subsidies for incontinence products in Japan in 2019. Family caregivers answered questions about toileting assistance, the perceived physical, emotional, and financial burdens of providing toileting assistance at home, and the urinary/fecal symptoms of older adults. Results: Of the 242 family caregivers who reported each burden, 213 (88%) had experienced at least one physical, emotional, or financial burden. The prevalence of physical, emotional, and financial burdens was 77.3%, 78.1%, and 70.7%, respectively. Approximately 60% of respondents reported experiencing all three burdens. Physical burden was associated with spouses acting as primary caregivers, nocturia, fecal incontinence, and the odor of urine/feces from toileting assistance. Emotional burden was associated with nighttime assistance, urinary/fecal leakage from absorbent incontinence products, and the odor of urine/feces. Financial burden was associated with frequent assistance, disposal costs of absorbent incontinence products, and the degree of toileting assistance. Conclusions: The results revealed a high prevalence of the three burdens of toileting assistance among family caregivers, suggesting the need to assess these burdens. Furthermore, they suggested the importance of providing guidance to family members, which may help reduce these burdens. [ABSTRACT FROM AUTHOR]

Objectives: A large‐scale nationwide epidemiological survey of lower urinary tract symptoms (LUTS) was conducted via the Internet in 2023 to clarify the current prevalence of LUTS and evaluate its impact on daily life in Japan. Methods: The survey was conducted among individuals aged 20–99 years old who had anonymously registered with a Japanese online research company. The survey consisted of 48 questions related to LUTS and daily life. Results: A total of 6210 participants (3088 females and 3122 males), who were selected by probability sampling based on the composition of the Japanese population (age range: 20–99), were recruited. The overall prevalence of LUTS was 77.9% among the subjects aged ≥20 and 82.5% among those aged ≥40. The prevalence of LUTS differed between the sexes and trends toward significant increases in prevalence with age were seen for almost all LUTS. Furthermore, the prevalence of overactive bladder (OAB) was 11.9% among the subjects aged ≥20 and 13.8% among those aged ≥40. This study also showed that LUTS negatively affected daily life. However, the percentage of subjects who visited a physician to receive treatment for LUTS was low, including for participants with a history of treatment for LUTS, although this increased with age. Conclusion: The prevalence of LUTS, including OAB, increased with age and negatively affected daily life. However, since the percentage of patients who visit a physician to receive treatment for LUTS remains low, further educational activities regarding LUTS are necessary. [ABSTRACT FROM AUTHOR]

This study aimed to identify differences in caregiver burden related to toileting assistance, and examine the factors associated with the most burdensome aspects of providing toileting assistance. In 2019, a self-administered postal survey was conducted with 743 caregivers of older adults who received subsidies for continence products in Komatsu City, Japan. Both family caregivers and nursing home staff answered questions regarding older adults' urinary/fecal symptoms, toileting assistance, and perceived caregiver burden. Older adults living at home had less need for toileting assistance than those in nursing homes. However, family caregivers experienced more burden than nursing home staff. The most frequent physical burden associated with toileting assistance for family caregivers was urinary/fecal leakage from absorbent incontinence products. This burden was linked to family caregivers providing care at home, using a combination of urinary pads and diapers, and symptoms that caused burdens on caregivers including urinary/fecal incontinence, nocturia, and no desire to urinate. These results suggest that leakage caused by the inappropriate use of urinary pads combined with diapers is a source of caregiver burden. Continence care experts should provide guidance to family caregivers of older adults, particularly those who are underweight and frail, regarding the selection and fitting of absorbent incontinence products. [ABSTRACT FROM AUTHOR]

Aim: To epidemiologically determine post‐void residual urine volume (PVR) and identify the characteristics of "potential" older adult patients with voiding dysfunction in an acute‐care hospital. Methods: A cross‐sectional study was conducted on 614 older adult patients in an acute‐care hospital between November 2018 and May 2019. Using portable ultrasound devices, nurses measured the patients' PVR three times after admission. Lower urinary tract symptoms were evaluated using the Core Lower Urinary Tract Symptom Score prior to admission. Results: A total of 107 older adult patients (17.4%) had episodes of abnormal PVR ≥100 mL. An age of over 75 years (adjusted odds ratio [aOR]: 1.899) and feeling of incomplete emptying (aOR: 4.337) were associated with having at least one episode of abnormal PVR, whereas neurological or circulatory diseases (aOR: 3.699) were associated with having two or three episodes. Conclusions: The results showed a high prevalence of abnormal PVR in older adult patients. Screening for PVR in older adult patients aged over 75 years who experience incomplete emptying or neurological or circulatory diseases may help identify those at risk for voiding dysfunction. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Postpartum urinary retention requires timely detection and intervention as late detection can lead to long-term voiding dysfunction; however, trends in the prevalence of urinary retention during the postpartum period remain unclear. This systematic review and meta-analysis aimed to estimate the pooled overall prevalence of overt and covert urinary retention in women after vaginal delivery and the difference in prevalence within 4 days after delivery. Methods: MEDLINE, CINAHL, Ichu-shi web, and J-stage databases were searched up until October 2020. Two researchers screened and included observational studies reporting the prevalence of urinary retention up to 4 days postpartum based on inclusion criteria. The overall prevalence of overt and covert urinary retention was calculated. Results: From 24 studies, the overall overt and covert urinary retention prevalence rates were estimated to be 1% and 13%, respectively. The prevalence of overt urinary retention over time was 2% at 6 h postpartum, 1% at 6–12 h, and 3% from postpartum to 24 h postpartum. The prevalence of covert urinary retention over time was 19% (6 h postpartum), 15% (24 h postpartum), 11% (1 day postpartum), 7% (2 days postpartum), 8% (3 days postpartum), and 0.1% (4 days postpartum). Conclusions: By postpartum day 4 after vaginal delivery, 14% of women were found to have experienced urinary retention. The highest prevalence was observed at 6 h postpartum, suggesting that urinary retention could be identified at 6 h postpartum. [ABSTRACT FROM AUTHOR]

Background: Pregnancy results in physical and psychological changes in women; however, pregnant women hesitate to take a break from work even when they feel the need. Since working while physically ill leads to decreased job performance, it is important to determine the factors that lead to this phenomenon.Aim: To study the occupational stress associated with job performance and absenteeism of pregnant women compared with non-pregnant women.Methods: In 2019, non-pregnant and pregnant employed women in their 20-40 s in Japan completed an online survey examining job performance (Work Limitation Questionnaire - Short Form), absenteeism, occupational stress (Brief Job Stress Questionnaire), and working situations.Results: Of 918 respondents who met the inclusion criteria, 904 were included in the final analysis (454 non-pregnant and 450 pregnant women). Logistic regression analyses showed that absenteeism was significantly higher for pregnant women. However, for women who were absent, there was no significant difference between non-pregnant and pregnant women. After adjusting for attributes and working conditions, pregnant women had significantly higher (p < .001) work productivity losses than non-pregnant women, but only in the physical tasks domain; their physical stress response was also higher compared to non-pregnant women (p = .048). However, pregnant women reported significantly less interpersonal conflict stress (p < .001) and psychological stress (p = .026), as well as better workplace support as a buffering factor for stress (p = .021), than non-pregnant women.Conclusion: Clarifying the physical burden associated with pregnancy and assisting women in coordinating their work duties while considering the physical demands of pregnancy may minimize work productivity losses among pregnant women. [ABSTRACT FROM AUTHOR]

Objectives: Women working in the medical field may be at risk for pelvic floor dysfunction due to high physical activity levels leading to increased abdominal pressure; however, the actual situation remains unknown. This study aimed to clarify the prevalence of symptoms of pelvic floor dysfunction and its associated factors among Japanese women working in the medical field. Methods: A cross‐sectional study was conducted among female employees at a public hospital in Japan from July to August 2020. Participants answered a web‐based questionnaire. Three types of symptoms related to pelvic floor dysfunction were assessed based on one or more subscale scores in the Pelvic Floor Distress Inventory‐Short Form 20 (PFDI‐20). Results: Out of 466 female employees in the hospital, 294 responded (response rate 63.1%). The mean age was 42.8 ± 10.3 years old and 221 (73.5%) were nurses. The prevalence of at least one type of symptom was 63.9%. The prevalence of recto‐anal symptoms (45.9%) was highest, followed by lower urinary tract (37.1%) and pelvic organ prolapse symptoms (22.8%). The total PFDI‐20 score was associated with constipation (β =.254), body mass index (β =.136), and part‐time work (β =.167) after adjusting for other variables. Conclusion: This study showed a high prevalence of symptoms related to pelvic floor dysfunction among women working in the medical field. Lifestyle management to prevent constipation and obesity is a promising strategy to improve symptoms of pelvic floor dysfunction. [ABSTRACT FROM AUTHOR]

Aims: Many stroke patients cannot urinate independently due to motor and cognitive dysfunctions. This study examined whether a continuous continence self‐management program during acute and convalescent phases is associated with independence in voiding behavior. Methods: A retrospective cohort study was conducted among stroke patients registered in the Council of Kaga Local Stroke Network, Japan, from 2015 to 2019. In the intervention group (n = 941), a multidisciplinary continence care team and ward nurses provided continence care in the acute phase and shared the information with the staff in the convalescent ward. The control group (n = 579) received traditional voiding care from ward nurses. The primary and secondary outcomes were independence in voiding behavior at discharge from the convalescent ward and length of hospital stay, respectively. Results: At discharge from the convalescent wards, the proportion of patients who voided at the toilet or bedside commode was higher in the intervention group than in the control group (76.3% vs. 62.4%, p < 0.001). The continuous continence self‐management program was associated with independence in voiding behavior (adjusted odds ratio: 1.801, 95% confidence interval [CI]: [1.102, 2.942]; p = 0.019) and length of hospital stay (β: −0.178, 95% CI: [−14.320, −7.607]; p < 0.001) after adjusting for other variables. Conclusions: The program was associated with increasing independent voiding behavior and shortened the length of hospital stay, suggesting the importance of promoting treatments for lower urinary tract symptoms and rehabilitation by a multidisciplinary continence care team for stroke patients. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of point-of-care ultrasound (POCUS) for nurses has been demonstrated; however, only a limited number of nurses have been trained to perform POCUS. This article reports on a POCUS train-the-trainer program for nurse educators that targets lower urinary track dysfunction. Method: Nurse educators (n = 38) were invited to participate in a POCUS train-the-trainer program, which comprised an e-learning module and a hands-on seminar. Acquisition of knowledge and skills were assessed after the module and seminar, respectively. Results: Questions from the "Basic Knowledge of Ultrasonography" test were answered correctly at a rate of 93.0% (SD, 8.5%). Measured values of bladder urinary volume using ultrasonography were in close agreement with actual values. All of the participants indicated that the program covered the content necessary to use in practice. Conclusion: The POCUS train-the-trainer program equips nurse educators with the knowledge and skills needed for training nurses at their institutions. [J Contin Educ Nurs. 2021;52(8):375–381.] [ABSTRACT FROM AUTHOR]

Aim: To estimate diagnostic accuracy of ultrasonography for detecting aspiration and pharyngeal residue in patients with dysphagia. Methods: A systematic search was conducted in MEDLINE (via PubMed), CINAHL, EMBASE, Ichushi‐Web, and Cochrane Library databases to identify articles that showed diagnostic accuracy of ultrasonography for detecting aspiration and residue published in English and Japanese until August 2019. Cross‐sectional studies, case–control studies, and cohort studies were included. The diagnostic accuracy results were extracted and the pooled estimated sensitivity and specificity were calculated. The risk of bias of the studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies 2. The certainty of the evidence was assessed using the Grades of Recommendation Assessment, Development, and Evaluation methodology. Results: Five studies were included in this review. The pooled estimated sensitivity and specificity for detecting aspiration were 0.82 (95% CI: 0.72–0.89) and 0.87 (95% CI: 0.81–0.92), respectively. One study was included that evaluated ultrasound assessments of pharyngeal residue. The sensitivity and specificity were 0.62 (95% CI: 0.32–0.86) and 0.67 (95% CI: 0.22–0.96), respectively. The certainty of the evidence was low and very low for the diagnostic accuracy of aspiration and pharyngeal residue, respectively. Conclusion: Ultrasound is a non‐invasive method with good sensitivity and specificity in detecting aspiration as well as reference standards. While risk of bias and small number of studies limited the strength of this systematic review, our results suggested that ultrasound examination was useful as a bedside screening tool for detecting aspiration. [ABSTRACT FROM AUTHOR]

Background: Energy inadequacy has a great impact on health outcomes in older adult patients; however, it is difficult to evaluate energy adequacy in these patients, especially in home-care settings. We recently reported that temporal muscle thickness can be an indicator of nutritional status. The present study aims to examine whether a change in temporal muscle thickness is directly correlated with energy adequacy and, if so, to determine the cutoff value of a change in temporal muscle thickness to detect energy inadequacy.Methods: A prospective cohort study was conducted from September 2015 to June 2016 in two hospitals in Japan, and included bedridden older adult patients aged ≥65 years. Temporal muscle thickness was measured using ultrasonography. Energy intake was estimated by photographic diet records. Total energy expenditure (TEE) was estimated by multiplying basal energy expenditure calculated using the Harris- Benedict equation by activity and stress factors. Energy adequacy was then calculated by dividing TEE by energy intake. Pearson's correlation coefficient was used to examine the relationship between percentage change in temporal muscle thickness and energy adequacy. Multiple logistic regression analysis was conducted to determine the direct relationship between percentage change in temporal muscle thickness and moderate energy inadequacy (energy adequacy< 75%). Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point for percentage change in temporal muscle thickness to detect moderate energy inadequacy.Results: Forty-eight patients were analyzed (mean age 84.4 ± 7.8 years; 54.2% were women). The percentage change in muscle thickness was significantly correlated with energy adequacy (r = 0.733, p < 0.001). ROC analysis identified a percentage change in temporal muscle thickness of - 3.6% as the optimal cutoff point for detecting moderate energy inadequacy. Percentage change in muscle thickness was independently correlated with energy inadequacy after adjusting for age, sex, and masticatory status (AOR 0.281, 95% CI 0.125-0.635).Conclusions: Changes in temporal muscle thickness are directly correlated with energy adequacy and can indicate moderate energy inadequacy in bedridden older adults. These results suggest the assessment of changes in temporal muscle thickness could be useful for guiding nutritional care in older adult patients in home-care settings. [ABSTRACT FROM AUTHOR]

Aim: Nurses have difficulty assessing the type of constipation by ordinal assessment methods and may therefore struggle to select an appropriate defecation care. Although previous studies described the safety and effectiveness of defecation care based on ultrasonographic observations in the colorectum, no standardized educational program has been established. This study aimed to determine the feasibility of the constipation point‐of‐care ultrasound (POCUS) educational program regarding the use of ultrasonography as an assessment tool to determine different types of constipation. Methods: This descriptive study was conducted for visiting nurses working in Japan. The constipation POCUS educational program that nurses can learn in as short as 7 days comprised four elements: E‐learning, a hands‐on seminar, self‐learning, and objective structured clinical examinations (OSCEs). The nurses were asked to complete a questionnaire regarding the education materials. OSCEs were used to assess the participants' skills in assessing patients based on the use of ultrasound observation in the colorectum. Results: Of the 44 participants who enrolled, 40 were able to complete the program. All the 40 participants (100.0%) who took the OSCEs were able to pass at the first attempt. Moreover, 94.9% of the trainees indicated that this program was able to cover the content necessary to use ultrasonography in home care settings. Conclusions: The results of this study suggest that the 7‐day constipation POCUS educational program provided trainees with a foundational knowledge and skills to observe fecal retention in the colorectum. Thus, further educational program enhancements and clinical skill evaluations are needed to maximize the program's effectiveness in the future. [ABSTRACT FROM AUTHOR]

Aim: The present study aimed to analyze the use of machine learning in ultrasound (US)‐based fecal retention assessment. Methods: The accuracy of deep learning techniques and conventional US methods for the evaluation of fecal properties was compared. The presence or absence of rectal feces was analyzed in 42 patients. Eleven patients without rectal fecal retention on US images were excluded from the analysis; thus, fecal properties were analyzed in 31 patients. Deep learning was used to classify the transverse US images into three types: absence of feces, hyperechoic area, and strong hyperechoic area in the rectum. Results: Of the 42 patients, 31 tested positive for the presence of rectal feces, zero were false positive, zero were false negative, and 11 were negative, indicating a sensitivity of 100% and a specificity of 100% for the detection of rectal feces in the rectum. Of the 31 positive patients, 14 had hard stools and 17 had other types. Hard stool was detected by US findings in 100% of the patients (14/14), whereas deep learning‐based classification detected hard stool in 85.7% of the patients (12/14). Other stool types were detected by US findings in 88.2% of the patients (15/17), while deep learning‐based classification also detected other stool types in 88.2% of the patients (15/17). Conclusions: The results showed that US findings and deep learning‐based classification can detect rectal fecal retention in older adult patients and distinguish between the types of fecal retention. [ABSTRACT FROM AUTHOR]

Aim: Nurses have the potential to perform fiberoptic endoscopic evaluation of swallowing (FEES) in Japan, which can aid in their provision of swallowing care appropriate to individual patients' swallowing functions. We aimed to confirm the safety and effectiveness of a new nursing education program on FEES by examining its impact on autonomy in performing FEES and accuracy in observing bolus swallowing. Methods: In this prospective descriptive study, we developed a FEES education program comprising three phases: (a) obtaining knowledge and skills through e‐leaning and a practical workshop; (b) becoming proficient in skills for assessing healthy adults through self‐learning; and (c) obtaining clinical competence through 30 cases of on‐the‐job training (OJT). The trends in autonomy and in accuracy of FEES were evaluated by the data during OJT. Results: Of the three certified nurses in dysphagia nursing, a trainee completed 30 cases of OJT and the other two trainees experienced 20 cases and 10 cases, respectively without any adverse event. Autonomy in the four major FEES skills gradually increased over the OJT. The correct answer rate, sensitivity, and specificity of the penetration‐aspiration scale and severity of residue in the pyriform sinus and epiglottis valley were above 95% at the first 10 cases of OJT among three trainees and they were 100% after the 11th case of OJT. Conclusions: Our results suggest that the developed education program helped nurses with experience being present at FEES obtain sufficient knowledge and skills to appropriately and safely perform FEES with 30 cases of OJT. [ABSTRACT FROM AUTHOR]

Aim: To verify the efficacy of defecation care based on handheld ultrasonographic observations for functional constipation by visiting nurses skilled in bowel ultrasonography. Methods: Home‐care patients with suspected functional constipation receiving nursing visits were recruited in this multiple‐baseline, single‐case experiment with intervention points shifted by 1 week. A total of 15 older adults were categorized into 3‐, 4‐, 5‐ or 6‐week intervention phases. Ultrasonographic observations of fecal retention in the colorectum and defecation care based on observations during the ordinal physical assessment were reviewed. Tau‐U was used for confirming the efficacy of the intervention by measuring the number of non‐artificial and artificial defecations, as well as hard stools per week, and the amount of non‐stimulant and stimulant laxatives, enemas and suppositories per week. For evaluating safety, adverse events, such as bowel obstruction and incontinence‐associated dermatitis, were confirmed. Results: No adverse events were observed. Statistical analysis showed that hard stools and artificial defecation reduced, and that their effect sizes were significant (Tau = −0.48, P < 0.01; Tau = −0.53, P < 0.01). Even the amounts of stimulant laxative and glycerin enema reduced, and their effect sizes were significant (Tau = −0.56, P < 0.01; Tau = −0.34, P = 0.04). Conclusions: Thus, defecation care based on ultrasonographic assessment by nurses in home‐care settings is safe and effective for improving constipation symptoms and reducing laxative use. Geriatr Gerontol Int 2020; ••: ••–••. [ABSTRACT FROM AUTHOR]

Bladder urine volume has been estimated using an ellipsoid method based on triaxial measurements of the bladder extrapolated from two-dimensional ultrasound images. This study aimed to automate this process and to determine the accuracy of the automated estimation method for normal and small amounts of urine. A training set of 81 pairs of transverse and longitudinal ultrasound images were collected from healthy volunteers on a tablet-type ultrasound device, and an automatic detection tool was developed using them. The tool was evaluated using paired transverse/longitudinal ultrasound images from 27 other healthy volunteers. After imaging, the participants voided and their urine volume was measured. For determining accuracy, regression coefficients were calculated between estimated bladder volume and urine volume. Further, sensitivity and specificity for 50 and 100 ml bladder volume thresholds were evaluated. Data from 50 procedures were included. The regression coefficient was very similar between the automatic estimation (β = 0.99, R2 = 0.96) and manual estimation (β = 1.05, R2 = 0.97) methods. The sensitivity and specificity of the automatic estimation method were 88.5% and 100.0%, respectively, for 100 ml and were 94.1% and 100.0%, respectively, for 50 ml. The newly-developed automated tool accurately and reliably estimated bladder volume at two different volume thresholds of approximately 50 ml and 100 ml. [ABSTRACT FROM AUTHOR]

Aims: To clarify longitudinal change of lower urinary tract symptoms (LUTS) and various types of urinary incontinence following robot‐assisted radical prostatectomy (RARP) using validated questionnaires. Materials and methods: The core lower urinary tract symptom score (CLSS) and the International Consultation on Incontinence Questionnaire (ICIQ)‐Short Form (SF) questionnaires were administered to 607 consecutive, treatment‐naïve men receiving RARP before and after surgery. The time course of comprehensive LUTS and various types of urinary incontinence, including stress‐, urgency‐, and urinary incontinence with no obvious reason, were evaluated. Continence recovery rates were compared for the different types of incontinence using Cox hazard regression analysis. Results: After surgery, stress urinary incontinence (SUI) was reported most frequently (32% of cases) as the chief complaint with the most impact on daily life, as assessed by the CLSS questionnaire, followed by urgency urinary incontinence (UUI; 27% of cases). The rates of continence recovery differed among the different types of urinary incontinence, such as after urinating, when dressed, when asleep, when physically active or exercising, when coughing or sneezing, before reaching the toilet, and for no obvious reason. Incontinence for no obvious reason at 1 month after RARP was a strongest prognostic factor of delayed continence recovery (hazard ratio, 0.61; P < 0.0001), whereas patients reporting SUI and UUI gradually regained continence. Conclusions: Further time course on continent recovery after RARP would be more precisely predictable based on the incontinence status at one month postoperatively. Especially, incontinence with no obvious reason would be a significant factor for delayed recovery. [ABSTRACT FROM AUTHOR]

Aim: Temporal muscle wasting is subjectively evaluated during nutritional assessment of protein–energy malnutrition. However, a quantitative evaluation method has not been established. The aim was to verify the validity and reliability of temporal muscle thickness measurement in comparison with established indicators of nutritional status, such as body mass index. Methods: A cross‐sectional study was carried out from September 2016 through June 2017. A total of 73 individuals aged ≥65 years were recruited from two facilities and one community walking group. Temporal muscle thickness was measured using ultrasonography. Nutritional status was assessed with anthropometric measurements and laboratory examinations. Results: For validity, the temporal muscle thickness showed strong correlations with muscle mass, including calf circumference (r = 0.608, P < 0.001) and arm muscle circumference (r = 0.433, P < 0.001). In contrast, no strong correlations were observed with serum protein levels, such as albumin (r = 0.324, P = 0.005), or fat mass evaluated as triceps skinfold thickness (r = 0.216, P = 0.067). Temporal muscle thickness was significantly related to body mass index after adjusting for possible confounding factors of masticatory status, age and sex (β = 0.335, P = 0.007). As for reliability, the intrarater reliability of the temporal muscle measurement was 0.99 (95% confidence interval 0.98–1.00). Bland–Altman plot analysis showed no systematic errors, and the coefficient of variation of temporal muscle thickness measurements was 2.3%. Conclusions: The present study suggests that measuring a temporal muscle thickness using ultrasonography is a valid and reliable method for evaluating nutritional status. Geriatr Gerontol Int 2019; 19: 135–140. [ABSTRACT FROM AUTHOR]

Aims: To determine whether ultrasound‐assisted prompted voiding (USAPV) care is more efficacious than conventional prompted voiding (CPV) care for managing urinary incontinence in nursing homes. Methods: Thirteen participating nursing homes in Japan were randomized to CPV (n = 7) or USAPV care group (n = 6). Residents of the allocated nursing homes received CPV (n = 35) or USAPV (n = 45) care for 8 weeks. In the CPV group, caregivers asked the elderly every 2‐3 h whether they had a desire to void and prompted them to void when the response was yes. In the USAPV group, caregivers regularly monitored bladder urine volume by an ultrasound device and prompted them to void when the volume reached close to the individually optimized bladder capacity. Frequency‐volume chart was recorded at the baseline and after the 8‐week intervention to measure the daytime urine loss. Results: The change in daytime urine loss was statistically greater in the USAPV (median, −80.0 g) than in the CPV (median, −9.0 g; P = .018) group. The proportion of elderly individuals whose daytime urine loss decreased by >25% was 51% and 26% in the USAPV and CPV group, respectively (P = .020). Quality‐of‐life measures of elderly participants showed no significant changes in both groups. The care burden scale score of caregivers was unchanged in the USAPV group (P = .59) but significantly worsened in the CPV group (P = .010) after the intervention. Conclusions: USAPV is efficacious and feasible for managing urinary incontinence in nursing homes. [ABSTRACT FROM AUTHOR]

Aims: The efficacy of perioperative pelvic floor muscle training (PFMT) for continence recovery after robot‐assisted radical prostatectomy (RARP) remains unclear. Visualization of the bladder neck and urethra using transperineal ultrasound (US) may promote self‐recognition of urethral closure during PFM contraction. This study aimed to examine whether transperineal US‐guided PFMT promotes early recovery of post‐RARP incontinence. Methods: This prospective cohort study included 116 men undergoing RARP. All men were offered to undergo transperineal US‐guided PFMT, and 36 men agreed. The protocol consisted of biofeedback PFMT using transperineal US before RARP and 1‐month after RARP with verbal instruction of PFMT immediately after urethral catheter removal. The remaining 80 patients received verbal instruction for PFMT alone. Continence recovery was defined as the number of days requiring a small pad (20 g) per day by self‐report. Results: No differences were observed in demographic or peri‐operative parameters between the two groups except the longer operative time in the US‐guided PFMT group. The mean time until continence recovery was significantly shorter in the US‐guided PFMT group (75.6 ± 100.0 days) than in the verbal‐PFMT group (121.8 ± 132.0 days, P = 0.037). Continence recovery rates within 30 days were 52.8% (19/36) and 35.4% (28/80) in the US‐guided PFMT and verbal‐PFMT groups, respectively (P = 0.081). US‐guided PFMT was associated with better postoperative continence status (adjusted hazard ratio [95% confidence interval]: 0.550 [0.336‐0.900], P = 0.017). Conclusions: The results showed that transperineal US‐guided PFMT perioperatively was associated with early recovery of urinary continence after RARP. [ABSTRACT FROM AUTHOR]

We previously reported elevated oxidative stress-related mechanical vulnerabilities of the skin as sparse distributions of hyperechoic areas. Although this helped establish a personalized skin care system to prevent skin disorders related to mechanical stress, obesity-related skin vulnerability involves individual differences. Here, we hypothesized that individual differences are caused by polymorphisms of GT repetitive sequences in the heme oxygenase1 (HMOX1) promoter region, which encodes an antioxidant enzyme. This cross-sectional study enrolled healthy male volunteers in a walking classroom aimed at weight control. Subjects with a body mass index <25 kg/m2 were classified as non-obese and those with body mass index ≥25 kg/m2 were classified as obese. Subject skin was categorized into sparse dermis or normal groups according to the distribution of hyperechoic areas by high-resolution skin ultrasonography (20 MHz). Genomic DNA and mRNA extracted from three body hairs with attached follicle cells were used to analyze GT repetitive sequences of the HMOX1 promoter, HMOX1 mRNA expression levels, and oxidative stress levels (8-hydroxy-2’-deoxyguanosine). Classifications of GT repetitive sequence of HMOX1 promoter were Short (<27 times) and Long (≥27 times). Higher numbers of subjects with sparse dermis were in the obese group compared with the non-obese group. In obese subjects, the number of subjects that had the Long allele of the HMOX1 promoter with sparse dermis was significantly higher compared with the normal group, whereas no association was observed between the polymorphism and ultrasonographic features in non-obese subjects. Thus, HMOX1 polymorphisms detected a risk of low collagen density in Japanese obese male subjects. [ABSTRACT FROM AUTHOR]

Aims Quality of life in the context of intermittent self-catheterization varies depending on the type of catheter used. This study translated into Japanese, evaluated the feasibility, reliability, and validity of the Intermittent Self-Catheterization Questionnaire (ISC-Q) among users of both reusable and disposable catheters, and examined the differences of it between them. Methods Seventy patients (age mean ± SD: 62.8 ± 17.7 years) completed the Japanese version of the ISC-Q (J-ISC-Q) at baseline and 4 weeks later. Spearman's correlation coefficients between the J-ISC-Q, and Qualiveen® and the SF-12 were used for the translated scale's discriminant and convergent validity. Reliability was evaluated by intraclass correlation coefficients (ICC), the Bland-Altman method, and Cronbach's alpha. Results Participants answered all questionnaire items with no difficulties. Scores on the convenience domain were significantly higher among reusable compared to disposable catheter users ( P = 0.039). The J-ISC-Q had significantly strong correlations with the Qualiveen® total scale ( ρ = −0.712 to −0.237), but weak correlations with the SF-12 total scale ( ρ = −0.231 to 0.474). Internal consistency was good (Cronbach's alphas > 0.706), and test-retest reliability was acceptable (ICC > 0.6) for the total scale and the four J-ISC-Q domains. The Bland-Altman analysis showed no systematic error between scores at baseline and 4 weeks later for the total scale and four domains of the J-ISC-Q. Conclusions The J-ISC-Q has acceptable reliability and validity for assessing both reusable and disposable catheter users, and can be used to promote tailored individualized interventions based on the impact of catheter use. [ABSTRACT FROM AUTHOR]

Aims To evaluate differences in motor learning of pelvic floor muscle (PFM) contraction between women with and without stress urinary incontinence (SUI) under transabdominal ultrasonography (TAUS)-guided PFM training. Methods Postpartum women received an intensive 3-month PFM training program from 3 to 6 months postpartum. The program consisted of home exercises and weekly group sessions with individual TAUS-guided training. Motor learning progress of PFM contraction was evaluated with TAUS at each weekly session. We regarded a woman who contracted her PFM correctly more than 9 times out of the 10 repetitions as having achieved the associative stage of motor learning. Women were evaluated before and after a 12-week intervention for PFM and SUI by using transperineal ultrasonography and questionnaire, respectively. Results Seventy-three women were included: 44 primiparous women (60.3%) and 64 vaginal deliveries (87.7%). Of 73 women, 22 (30.1%) were classified as the SUI group. By the fifth session, the proportion of women who could correctly contract their PFM > 9 out of the 10 repetitions had increased significantly more in the non-SUI group than in the SUI group (90.0% vs. 58.8%, P = 0.011). The proportion of women achieving the associative stage of correct PFM contraction was not different between the two groups after the sixth session. PF morphology and SUI were improved after intervention ( P < 0.05). Conclusions The proportion of women achieving the associative stage in women with SUI was less than that in women without SUI in the early phase of the combination of group and home PFM training with TAUS-guided training. Neurourol. Urodynam. 36:98-103, 2017. © 2015 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Objectives To assess the efficacy and feasibility of ultrasound-assisted prompted voiding for the management of urinary incontinence in nursing homes. Methods Nursing home residents who had received prompted voiding care for urinary incontinence were enrolled. The voided urinary volume and residual urinary volume were initially measured for a few days. The sum of the mean values of these volumes was considered as the optimal intravesical urinary volume for voiding. Thereafter, the participants underwent regular monitoring of intravesical urinary volume using an ultrasound device, and were prompted to void in a toilet when the monitored volume almost reached the optimal volume. The primary outcome for efficacy was the change in the absorbent cost before and after ultrasound-assisted prompted voiding care over 12 weeks. The feasibility was assessed by the change in activity of daily living of residents and quality of life measures of the care workers. Results A total of 77 residents completed the 12-week ultrasound-assisted prompted voiding intervention. The absorbent cost decreased in 40 participants (51.9%), and the overall cost decreased by 11.8% from the baseline value ( P = 0.006). The activity of daily living did not significantly change. The quality of life of the care workers significantly improved for subscales of role emotional ( P = 0.020) and mental health ( P = 0.007). Conclusions The management of urinary incontinence for nursing homes residents through ultrasound-assisted prompted voiding seems to reduce the absorbent cost and to partially improve care workers' quality of life. [ABSTRACT FROM AUTHOR]

Objectives In recent years Mongolia has made great advances towards Millennium Development Goals to reduce maternal and child mortality, however few studies have investigated maternal and child health status several years after childbirth. Our study aims to describe priority health issues in maternal and child health in Mongolia 3 years after childbirth, and key areas requiring further health policy development. Methods We conducted a population-based cross-sectional study in Bulgan province, Mongolia. Participants were women who gave birth in 2010 and lived in Bulgan in 2013, and their children who were almost 3 years of age. Data was collected using structured interviews, self-administered questionnaires, transcribed records from the Maternal and Child Health Handbook, anthropometric measurements, and a developmental assessment tool. Results Data was obtained from 1,019 women and 1,013 children (recovery rate: 94.1 %). Among women, 171 (17.2 %) were obese and had an average body mass index (BMI) of 25.7, 40 (4.4 %) experienced intimate partner violence (IPV) and 356 (36.2 %) reported urinary incontinence in the past month. Among children, 110 (10.8 %) were assessed as at risk of developmental delay, 131 (13.1 %) were overweight or obese, burns accounted for the highest number of serious accidents at 173 (17.0 %) while lower respiratory tract infections (LRTIs) were the most frequent cause of pediatric hospitalization. Conclusions for Practice Further development in health policy is required in Mongolia to target the significant health challenges of obesity, IPV, and urinary incontinence in women, and obesity, development delay, burns, and LRTIs in children. [ABSTRACT FROM AUTHOR]

Preventing pressure ulcers is important in patients undergoing procedures in the park-bench position. We hypothesized that the microclimate around the skin is a significant risk factor for developing pressure ulcers. This research continuously assessed factors of the microclimate in terms of skin temperature and perspiration as well as the interface pressure in order to determine whether the microclimate is an independent risk factor for the development of park-bench position-related pressure ulcers (PBP-PUs). A prospective observational study was conducted among patients undergoing elective surgery in the park-bench position at a general hospital in the metropolitan area of Japan between April and November 2014. Factors of the microclimate, including skin temperature and perspiration, in addition to the interface pressure were continuously measured throughout surgery. Twenty-nine patients were analyzed (mean age 44.4 ± 13.2 years, male 44.8%). Of these 29 patients, seven (24.1%) developed Category I PBP-PUs. The change in skin temperature from baseline to the end of surgery (2.7 ± 0.3 °C vs. 1.9 ± 0.8 °C) and the average peak pressure (119.1 ± 36.8 mmHg vs. 94.56 ± 3.1 mmHg) were significantly higher in the patients with PBP-PUs than in those without PBP-PUs. There were no significant differences in the amount of perspiration between the two groups. A hierarchical logistic regression analysis showed that the change in skin temperature was significantly related to the development of PBP-PUs (unit=0.1°C: odds ratio 1.44, 95% confidential interval 1.09-2.33) when adjusted for the average peak pressure and length of surgery. Our results suggest that a change in skin temperature toward a higher value is an independent risk factor for the development of PBP-PUs. Proper intraoperative management of skin temperature may therefore be a promising candidate as a preventive method against PBP-PU development. [ABSTRACT FROM AUTHOR]

Pressure ulcers result from tissue hypoxia caused by external forces. Thrombosis due to external forces is considered important, and hypoxia inducible factor-1 (HIF-1) is a master regulator of pressure ulcer development. To date, however, their causal relationship has not been determined. This study therefore investigated the mutual relationship between thrombosis and HIF-1 activation in compressed mouse skin, based on a hypothesis that HIF-1 regulation by plasminogen activator inhibitor-1 (PAI-1) enhances thrombosis. Compression of mouse skin significantly increased the numbers of thrombi and HIF-1α-positive cells compared with control skin. A thrombosis inhibitor significantly reduced the numbers of HIF-1α-positive cells and an HIF-1 inhibitor significantly inhibited thrombosis in compressed skin tissue, suggesting a mutual relationship between thrombosis and HIF-1 activation. Compression of mouse skin also enhanced the level of Pai-1 messenger RNA expression, but this increase was significantly reduced by treatment with an HIF-1 inhibitor, whereas a thrombosis inhibitor had no effect. These results suggested the involvement of PAI-1 in HIF-1-enhanced thrombosis and that an additional factor participates in regulating Pai-1 expression in compressed skin. These findings may suggest new strategies in pressure ulcer management. [ABSTRACT FROM AUTHOR]

ABSTRACT Predicting the short-term healing progress of pressure ulcers is important for providing timely and appropriate intervention. Although there are some prediction methods available, these are unsuitable for ulcers with abundant necrotic tissue. We aimed to elucidate the relationship between necrotic tissue alteration and protein distributions on ulcers to establish a new prediction method. Thirty-eight pressure ulcers were retrospectively analyzed. Protein distributions on necrotic tissue were evaluated by the wound blotting at three levels: marker protein positivity, signal patterns (speckled, heterogeneous, or homogeneous), and the occupation of heterogeneous pattern. Peroxidase, alkaline phosphatase, tumor necrosis factor α, and matrix metalloproteinase-2 were used as marker proteins. One-week necrotic tissue alteration was classified as liquefaction or nonliquefaction, and associations with protein distributions were analyzed. The peroxidase positivity was significantly higher in the liquefaction than in the nonliquefaction ( p = 0.031). In peroxidase-positive samples, the proportion of nonliquefaction samples was significantly higher in the heterogeneous pattern ( p = 0.029). In the heterogeneous-patterned samples, the proportion of samples with an occupation values greater than the median value tended to be higher in the nonliquefaction ( p = 0.087). There was no significant relationship between liquefaction and other markers. Peroxidase positivity predicts 1-week liquefaction of necrotic tissue, while a heterogeneous pattern indicates nonliquefaction. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aim of this study was to translate the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) into Japanese and test its reliability and validity among Japanese women. Methods: Fifty-nine women with and without pelvic floor disorders (age 55.8 ± 16.8 years, mean ± SD) completed the Japanese PFDI-20 (J-PFDI-20) questionnaire at baseline and 2 weeks later. Intraclass correlation coefficients (ICC) and the Bland and Altman method for test-retest reliability and Cronbach's alpha for internal consistency of the J-PFDI-20 were used. Scores of total and subscales were compared between women with and without pelvic floor disorders for known-groups validity. Spearman's correlation coefficients between the J-PFDI-20 and the severity of pelvic floor disorders and Urinary Incontinence Quality of Life Scale (I-QOL) were used for construct validity. Results: The PFDI-20 was successfully translated from English into Japanese with face validity through rigorous cross-cultural validation. Test-retest reliability of the J-PFDI-20 and three subscales was good to excellent (ICC = 0.77-0.90). The Bland and Altman analysis showed that differences between the first and second scores of total J-PFDI-20 and its subscales were not significantly different from 0 and largely fell within the range of 0 ± 1.96 SD. Cronbach's alpha values were 0.52-0.83. Analysis of known-groups validity showed differences in scores of the J-PFDI-20 between women with and without pelvic floor disorders. Acceptable construct validity was found in J-PFDI-20 total and subscale scores with positive correlations to severity of pelvic floor disorders ( ρ > 0.35) and negative correlations to I-QOL ( ρ < -0.39). Conclusions: The results suggest that the J-PFDI-20 is a reliable and valid condition-specific quality of life instrument for women with pelvic floor disorders. [ABSTRACT FROM AUTHOR]

Purpose: To compare the pelvic floor function between women with and without stress urinary incontinence after vaginal delivery. Methods: Seventeen women (age 35.5 ± 3.5) were prospectively studied at about 6 weeks, 3 months, and 6 months after vaginal delivery. Urinary incontinence was assessed by the International Consultation on Incontinence Questionnaire - Short Form. Pelvic floor function was assessed by antero-posterior diameter of the levator hiatus using transperineal ultrasound. Results: Five of 17 women experienced postpartum stress urinary incontinence. The antero-posterior diameter of the levator hiatus at rest was significantly longer in stress urinary incontinent women than in continent women until 3 months after delivery ( p < 0.01), though shortening of the antero-posterior diameter of the levator hiatus was not significantly different between continent women and stress urinary incontinent women. Regardless of urinary incontinence, the antero-posterior diameter of the levator hiatus at rest shortened at 6 months postpartum, compared to 6 weeks postpartum ( p < 0.001). The antero-posterior diameter of the levator hiatus during contraction had shortened only in continent women by 6 months postpartum ( p = 0.02). Conclusion: The extended pelvic floor may be a cause of stress urinary incontinence in the postpartum period. Therefore, treatment to improve the extended pelvic floor should be developed for the prevention of stress urinary incontinence. [ABSTRACT FROM AUTHOR]

Purpose: To assess the utility of transperineal three-dimensional (3D) ultrasound for diagnosing anal sphincter defects and evaluating the function of the anal canal in women with anal incontinence. Methods: The study subjects were 13 women with anal incontinence. Symptoms of fecal incontinence were assessed by Wexner score. The anal canal of each woman was examined ultrasonically with both a convex transperineal 3D scanner and a radial transanal scanner to compare the accuracy of the two approaches for diagnosis of anal sphincter defects. The anorectal angle and the length of the anal canal were also measured by utilizing the functionality of the transperineal 3D ultrasound. Results: The mean age was 58.9 ± 14.9 years (±SD), and the mean Wexner score was 8.4 ± 5.6. In terms of ultrasound diagnosis of anal sphincter defects, the two methods showed consistent results in each woman. The length of the portion where both the internal and external anal sphincters were intact was significantly correlated with the Wexner score, whereas the total length of the anal canal was not. Conclusions: Less invasive transperineal 3D ultrasound provides accurate evaluation of the internal and external anal sphincters in women with anal incontinence, and the method is potentially useful for detection of anal sphincter abnormalities. [ABSTRACT FROM AUTHOR]

Photolyses of thianthrene sulfilimine derivatives in the presence of several olefins were studied and found to afford the corresponding aziridines in good yields, particularly, in case of 2,8-dibromo-[5-(N-tosyl)imino]thianthrene. This reaction was considered to proceed via generation of nitrene by photolytic S-N bond cleavage of thianthrene sulfilimines. Further, photo-aziridination of olefins by thianthrene sulfilimine derivatives was intensively studied to make clear the ability as nitrene precursors. [ABSTRACT FROM AUTHOR]

Maternal mental illnesses during early postpartum may be caused by lack of the coparenting relationship parents share and cooperate regarding child-rearing. This study clarifies the association of the coparenting relationship and negative mental health of mothers at one and three months after childbirth. This study conducted a secondary analysis of data from an intervention study wherein 24 mothers rearing their first child with a cohabitant (husband/partner) participated. Maternal mental health was evaluated using the Edinburgh Postnatal Depression Scale to determine postpartum depressive symptoms and the Mother-to-Infant Bonding Scale to assess negative bonding. Mothers' average age was 31.5 ± 4.2 years old. All mothers were not working during the research period. The prevalence of postpartum depression and bonding disorder were approximately 13% and 21%, respectively. A better coparenting relationship was associated with lower postpartum depressive symptoms at both one month (β = −0.617, p = 0.002) and three months (β = −0.709, p < 0.01) postpartum. In contrast, no association was found between a coparenting relationship and negative bonding. The results indicate that the coparenting relationship may possibly prevent maternal depression during the early postpartum period. [ABSTRACT FROM AUTHOR]

According to the experience of nurses and physiotherapists, the abdomen of constipated people becomes softer after abdominal massage. However, the relationship between the decrease in abdominal stiffness and the benefits of abdominal massage has not been examined quantitatively and is unclear. Furthermore, devices for measuring stiffness have been designed to measure relatively hard areas such as the shoulders and do not take into account the lateral outflow of the target tissue, which can be a problem when measuring the stiffness of soft areas such as the abdomen. To address these issues, this study presents a stiffness sensor suitable for measuring abdominal stiffness and investigates the relationship between the reduction in abdominal stiffness and the benefits of abdominal massage. The solution to prevent the lateral outflow of the target is the realization of a stopper, including a contact detection device, which enables a wide-area contact around the targeted area. The sensor consists of a stopper, probe, spring, and time-of-flight (ToF) sensors. The probe and spring provide appropriate pressure and deformation to the abdomen, whereas the stopper prevents the probe from being pushed into the abdomen more than necessary. The ToF sensor measures the deformation length when the deformation is stopped by the stopper. The abdominal stiffness can be derived from the deformation length. The investigation results indicate that the reduction in abdominal stiffness corresponds to the improvement of the stool condition or the maintenance of a healthy stool condition, whereas the maintenance of abdominal stiffness indicates the maintenance or deterioration of the stool condition. [ABSTRACT FROM AUTHOR]

Physical activity (PA) during pregnancy is associated with maternal benefits. Therefore, innovative strategies that promote PA are needed. This study investigated the acceptability and feasibility of a sedentary behavior (SB) reduction program during pregnancy. The study employed a semi-experimental research design using historical control subjects. The intervention group program consisted of individual face-to-face guidance, automatic alerts during SB from wearable devices, and self-monitoring of SB patterns, from 20 gestation weeks to delivery. PA and SB, assessed using a wearable device, were compared with those of the control group at 24–27 (T1) and 32–35 (T2) weeks of gestation. In 56 women, the mean wearing time was 90.2 days in the intervention phase. The response rate to automatic SB alerts was 55.5% at T1 and 63.0% at T2. Self-monitoring more than twice or thrice a week was 77.8% at T1 and 59.3% at T2. There was no significant difference in the cumulative SB time at T2 between the two groups (F = 2.31, p = 0.132). This program appears to be acceptable and feasible for pregnant women; however, SB reduction effect of the intervention remains unclear. Improvements to increase the response rate to automatic SB alerts and the frequency of self-monitoring are needed. [ABSTRACT FROM AUTHOR]

The demand for methods to ensure safe oral consumption of food and liquids in order to prevent aspiration pneumonia has increased over the last decade. This study investigated the safety of swallowing care selected by adding ultrasound-based observation, evaluated its efficacy, and determined effective content of selected swallowing care. The study employed a pragmatic quasi-experimental research design. Participants were 12 community-dwelling adult patients (age: 44–91 years) who had experienced choking within 1 month prior to the study. After the control phase, in which conventional swallowing care was provided, trained nurses provided ultrasound observation-based swallowing care for a minimum period of 2 weeks. Outcome measurements were compared across three points, namely T1—beginning of the control phase, T2 and T3—before and end of the intervention phase. The mean durations of intervention were 30.8 days in the control phase and 36.5 days in the intervention phase. Pneumonia and suffocation did not occur in the control phase or the intervention phase. The safe intake food level and the food intake level score significantly improved during the intervention phase (p = 0.032 and 0.017, respectively) by adding eating training based on the ultrasound observation. However, there was no significant improvement in the strength of the muscle related to swallowing by the selected basic training. Our results suggest that swallowing care selected based on the ultrasound observation, especially eating training, safely improved safe oral intake among community-dwelling adults with swallowing dysfunction. [ABSTRACT FROM AUTHOR]

Nurses encounter difficulties evaluating constipation in elderly people with physical and cognitive impairment. Transabdominal ultrasonography (US) has been used to evaluate fecal impaction or fecal quality. However, it is unclear whether colorectal US can evaluate constipation symptoms in older people. Using colorectal US, we continuously observed the elderly and clarified the relationship between patterns of fecal distribution changes and constipation symptoms in older people with physical and cognitive impairment at long-term care facilities. This study included patients aged ≥65 years with oral intake. US was performed once a day until the next defecation, and fecal hardness was assessed. US images were extracted and categorized. Then, patterns of fecal distribution changes in the colorectum were classified. Multiple logistic regression analysis was performed to examine related factors associated with a constipation pattern. Among 101 patients, US images of 95 patients were analyzed. In 74.4% of the patients, US showed continuation of reflection with acoustic shadow in the rectum, which was significantly associated with defecation on the bed. Of the patients with a continuous crescent-shaped reflection pattern (R3), 92.9% had hard stool. R3 was found to be significantly associated with a Mini-Mental State Examination score of ≤10. In most of the patients, US detected a continuation of reflection with acoustic shadow in rectal patterns, indicating fecal retention in the rectum. Point-of-care US can be used by nurses to visualize rectal fecal retention as constipation patterns in the older people with physical and cognitive impairment at long-term care facilities. [ABSTRACT FROM AUTHOR]