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Postoperative delirium, a common perioperative complication, is frequently observed in elderly surgical patients. Few studies have investigated the life rhythm of preoperative patients, and whether or not the preoperative life rhythm is associated with the development of postoperative delirium. The purpose of this study was to investigate the relationship between the preoperative circadian physical activity rhythm and postoperative delirium in cardiovascular surgery patients. A total of 43 patients who underwent cardiovascular surgery were included in this prospective study between July 2016 and September 2017 at Kobe University Hospital. All subjects used a "Life Microscope" wristband (a wristwatch-type terminal incorporating a 3-axis accelerometer monitoring) for 3-7 days at home before the planned surgery. Hourly mean values were calculated for the metabolic equivalents from the obtained activity amounts, and subsequently evaluated using cosine periodic regression analysis. The circadian rhythm parameters of mesor (24 h time series mean), amplitude (half the peak-trough variation), and acrophase (peak time) for the metabolic equivalents were obtained. The intensive care delirium screening checklist was used to assess for postoperative delirium. The acrophase significantly advanced in the postoperative delirium group (median, 11:55 h [interquartile range, 11:06-12:27 h]) compared to the group without postoperative delirium (median, 13:25 h [interquartile range, 12:52-14:13 h]) (

Background The prevention of recurrent readmission among heart failure (HF) patients requires support for appropriate self-care behaviors to prevent exacerbation of HF and self-monitoring to allow for patients’ early perception of physical changes during exacerbations. Such support may enable patients to seek early consultation. This study developed a self-monitoring intervention that aimed at increasing the perception of patient-unique physical sensations caused by HF, based on daily activity records of patients. Method A parallel two-arm randomized controlled trial is being conducted with 68 HF patients early after their discharge. Participants in both groups wear a wristwatch activity tracker from time-of-discharge. Participants in the self-monitoring intervention group receive support to reflect on their actual daily activities and the associated physical sensations they experienced, based on their daily activity records. The primary outcome is participants’ “Asking for Help” dimension of self-care behavior, measured using the European Heart Failure Self-Care Behavior Scale at one month follow-up after intervention. Conclusion This study is the first trial to use an activity tracker as a tool for symptom perception among HF patients. The problem of delayed consultations during exacerbations may be resolved by assisting patients in improving their perception of their unique physical sensations associated with specific daily activities, based on their daily activity records. If the effect is clarified, it could lead to the construction of new nursing interventions for continuous disease management that aim towards re-hospitalization prevention.

BACKGROUND A substantial number of patients with shock devices (implantable cardioverter defibrillators [ICDs] or ICDs with resynchronization [CRTDs]) experience psychological distress. OBJECTIVE We investigated the device nurse telephone intervention's effect on improving the patient's adaptation to shock devices, quality of life (QOL), and anxiety in the remote monitoring era. METHODS The patient's adaptation to the device, health-related QOL, and anxiety were investigated by the modified Implanted Devices Adjustment-Japan score (IDAS), Short Form-36, and State-Trait Anxiety Inventory (STAI) before and 1-year after the device nurse telephone intervention, performed every 3 months. A total of 95 patients (median age 69 years and 25 females) participated. Sixty patients had ICDs and 35 CRTDs. Structural heart disease was observed in 72 patients, and idiopathic ventricular arrhythmias in the others. The mean left ventricular ejection fraction was 46% ± 15%. The median duration since the device implantation was 5.2 years. RESULTS The total IDAS score significantly improved from 28.42 ± 7.11 at baseline to 26.77 ± 7.68 (p = 0.0076) at 1 year. Both the state and trait anxiety significantly improved (from 38.9 ± 9.6 to 35.3 ± 9.0 [

Aim To develop the Questionnaire for Reflective Practice of Nursing Involving Invasive Mechanical Ventilation (Q‐RPN‐IMV), a Japanese self‐evaluation instrument for ward nurses’ IMV practices. Design Cross‐sectional survey. Methods Participants were 305 ward nurses from five hospitals in Japan with nursing involving invasive mechanical ventilation. Items concerning the process of nursing practice, including the thought process related to ventilator care, were collected from the literature and observation and interviews with five IMV specialists. Construct validity, concurrent validity, internal consistency and test–retest reliability were tested. Results Initially, 141 items were collected and classified into three domains (i.e., observation, assessment and practice). Examination of exploratory factor analysis yielded five factors in the observation domain, six factors in the assessment domain and six factors in the practice domain. The data exhibited internal consistency, stability and concurrent validity. Items of practical content, including thoughts on ventilator care, are useful for preparing educational programmes.

The objective of this study was to clarify the lifestyle characteristics of patients with alcoholic liver disease (ALD) who were readmitted to the hospital, and to identify the background factors associated with these characteristics. This was a prospective observational study. Over a period of 3 months following hospital discharge, we conducted structured interviews to investigate the following five lifestyle characteristics based on our previous research: dietary intake, alcohol consumption or abstinence, psycho-emotional status, regularity of life habits, adherence to treatment. We also collected data on background factors from medical records and questionnaires. The analysis was performed using conceptual cluster matrices, with participants divided into two groups (at-home recovery and readmission). Lifestyle, health status, and background factors were compared between the two groups. Of the 34 patients with ALD recruited, 21 completed the one-month follow-up and were included in the analysis—14 patients were in the at-home recovery group and 7 in the readmission group. The at-home group’s lifestyle was characterized by controlled alcohol consumption, but with maintenance of regular life and eating habits and adherence to treatment. In contrast, irregular eating habits (p=0.006) and the development of irregular life habits or the discontinuation of treatment very quickly after hospital discharge characterized the readmission group’s lifestyle. Experiences of loss were a lifestyle-related background factor that was associated with readmission (p=0.017). Based on these findings, supporting patients with ALD in maintaining regular eating habits and taking experiences of loss into consideration would be important in avoiding readmission over the short-term.

Bone cement implantation syndrome (BCIS) is a known complication in patients undergoing cemented orthopedic surgeries; however, the etiology and pathophysiology of BCIS are not fully understood. We report the case of a patient who developed pulseless electrical activity (PEA) due to BCIS after cemented femoral head replacement. Transesophageal echocardiography (TEE) during PEA revealed a massive embolus extending from the main pulmonary artery to the inferior vena cava. Of note, this embolus disappeared completely and rapidly after return of spontaneous circulation. TEE proved to be useful in the diagnosis and management of this case of PEA. Electronic supplementary material The online version of this article (10.1186/s40981-019-0225-2) contains supplementary material, which is available to authorized users.

This study aimed to clarify psychosocial influences of waiting periods on patients undergoing endoscopic submucosal dissection for cancer at an advanced medical care facility in Japan. Subjects were consenting patients hospitalized from 2009 to 2010. Qualitative and quantitative data were gathered about patients' characteristics, disease and stage, and waiting period. Qualitative content analysis was used to analyze free statements and interview data. Subjects included 154 patients with an average wait period of 46.28 days for admission. Qualitative analysis revealed the following wait period perceptions. For calmness, results indicated (1) no anxiety, (2) relief based on doctors' positive judgment, (3) whatever happens/no choice, and (4) trust in doctor. For uneasiness, perceptions included (1) the sooner, the better/eagerly waiting, (2) anxiety and concern, and (3) emotional instability. Four waiting period coping types were identified: (1) making phone inquiries, (2) busy and forgot about the medical procedure, (3) relief from anxiety, and (4) unable to function well in daily life. Patients need to be educated about cancer progression and provided an estimated wait time. They also require more information about how to manage daily life such as monitoring factors from the nursing domain including physical condition, digestive symptoms, diet, and exercise.

A 78-year-old woman (height: 1.6 m; weight: 71 kg) with sudden onset of left abdominal pain was diagnosed with an impending AAA rupture and was transferred to this hospital for surgical management. The patient had no remarkable medical history. Before surgery, her vital signs were blood pressure, 89/67 mmHg; heart rate, 104 beats per minute; respiratory rate, 34 breaths per minute; and oxygen saturation, 98% in room air. Blood tests indicated a hemoglobin level of 7.4 g/dL, normal renal function, and absence of any coagulation disor- ders. Electrocardiography indicated a normal sinus rhythm with no evidence of ischemia. Transthoracic echocardiography (TTE) showed normal left ventricular function (ejection frac- tion 450%) and no obvious valvular disease. A contrast- enhanced computed tomographic (CT) scan confirmed the presence of a 60-mm ruptured infrarenal AAA. A contrast- enhanced CT scan of the entire aorta found no evidence of dissection, intramural hematoma, or penetrative ulcers along the entire length of the ascending aorta. After the placement of peripheral intravenous and arterial catheters, the patient was transferred to the operating room for surgical repair of the AAA. Anesthesia was induced, unevent- fully, with 250 μg of fentanyl, 2 mg of midazolam, and 100 mg of rocuronium. She was intubated with a 7.0-mm endotracheal tube and received inhaled sevoflurane as maintenance anes- thesia. Thereafter, a central venous catheter was inserted through the right internal jugular vein. After her abdomen was opened, the hemorrhage from the aneurysm became uncontrollable. She suffered cardiopulmo- nary arrest (CPA) due to hemorrhagic shock. Therefore, a left anterolateral incision was made, and the cardiothoracic surgeon initiated cardiac massage. Moreover, the descending aorta was clamped through the incision. Thus, cardiopulmonary resusci- tation was attempted, and spontaneous circulation returned after approximately 24 min; hence, the surgery was resumed. Her activated coagulation time (ACT) was 340 seconds without heparin administration; therefore, heparin was not administered during the surgery. The infrarenal abdominal aorta and left and right common iliac arteries were identified and clamped. Thereafter, the patient underwent infrarenal abdominal aorta replacement with an I-graft (20 11 mm; Hemashield Gold, MAQUET, San Jose, CA). After the proximal aortic site was unclamped, the patient's blood pressure suddenly fell. Although appropriate medical and fluid therapies were administered, her vital signs remained unstable. Consequently, a TEE probe was inserted, which indicated the presence of an AAD extending along the aorta proximally from the aortic arch to the descending aorta. At that time, the dissection was limited to the aortic arch on the proximal side. After the distal site was unclamped, the patient suffered another CPA due to hypovolemic shock and required blood volume infusion and cardiac massage. She recovered quickly and underwent another TEE examination thereafter. TEE indicated that the dissection extended to the ascending aorta—which was suggestive of a retrograde type-A AD (Fig 1) —and showed the presence of moderate-to-severe AR, the absence of any apparent pericardial effusion, and the absence of any abnormal cardiac wall motion or coronary involvement. Within the visual field of the TEE, no entry site of the dissection was observed. After discussing the management of this patient with the cardiothoracic surgeons, conservative treatment was adopted for treating the dissection. After I-graft replacement for the AAA was completed, the patient was transferred to the intensive care unit (ICU) with an open abdomen and was intubated. She received an infusion of 0.1 μg/kg/min of norepinephrine and 0.7 μg/kg/min of epi- nephrine. The total amount of bleeding due to surgery was 1,074 mL, whereas 7,070 mL of blood were collected in the cell saver canister (Sorin Group, Milan, Italy). The patient required 34 U of packed red cells, 32 U of fresh frozen plasma, and 30 U of platelet concentrates to resolve the loss caused by hemorrhage during the surgery. Finally, her ACT was found to be 191 seconds without heparin administration.

A 97-year-old woman with severe back pain was transferred to our hospital. She was able to perform activities of daily living independently and had no neu- rological deficit or dementia before her admission. Con- trast-enhanced computed tomography revealed a rup- ture in the descending aorta and thrombosed type A aortic dissection. We carefully explained the need for and the risks associated with surgery to the patient and her family. After an informed consent had been obtained, she was taken to the operating room for an emergency surgery. Anesthetic management was uneventful. Trans- esophageal echocardiography was useful to evaluate her cardiac function and aortic dissection. We per- formed replacement of the total aortic arch and descending aorta successfully. On the 55th postopera- tive day, she was transferred to another hospital to undergo further physical therapy. The total hospital- ization cost was nearly 9.8 million yen. The medical cost was high in our case. In cases of nonagenarians who require an emergency cardiac surgery, we should consider the patients' age, preoperative activities of daily living, and postoperative quality of life when making decisions on surgery. The patient in our case needed to be carefully treated for airway and swallow- ing management in the early perioperative period.

OBJECTIVES: We assess differences in physical activity self-management behavior in association with dietary intake and BMI between the sexes in patients with type 2 diabetes. METHODS: Patients with type 2 diabetes (n = 145) completed a self-administrated questionnaire. Patients were classified into four groups by BMI and dietary intake: non-obesity and non-overeating (NO/NOE); non-obesity and overeating (NO/OE); obesity and non-overeating (O/NOE); obesity and overeating (O/OE). Differences in physical activity self-management behavior between the four groups were determined by the analysis of variance using a Tukey–Kramer post hoc test. RESULTS: Male O/OE group showed higher HbA1c (p = 0.001) than the other groups. Male NO/OE group had higher steps/day than O/NOE (p = 0.036) and score of “Exercising to stimulate the enjoyment of eating” was higher than O/OE (p = 0.031). Female NO/OE group showed higher HbA1c (p = 0.001) than NO/NOE and O/NOE. CONCLUSIONS: BMI and dietary intake were associated with frequencies of physical activity self-management strategies in men. Self-management behavior peculiar to male NO/OE group is “Exercising to stimulate the enjoyment of eating”. Health professionals should assess sex, BMI, and dietary intake of patients and endeavor to improve individuals’ ability to regulate their caloric balance based on physical activity level.

Evidence regarding nursing support for delirium prevention is currently insufficient. An evaluation of changes in autonomic nervous activity over time after surgery would elucidate the features of autonomic nervous activity in patients with delirium. These results could provide a basis for effective nursing intervention and timing for preventing the onset of delirium. Here, we aimed to obtain basic data on effective nursing interventions for preventing the onset of postoperative delirium. Heart rate variability was recorded during the morning and nighttime on the day before surgery until 3 days postoperatively in elderly patients who underwent orthopedic surgery to investigate the manner in which heart rate and autonomic nervous activity changed over time. Data were collected over 11 months from July 2013 to November 2014. Surgical stress led to the maintenance of heart rate at a significantly higher value from the day of the surgery until postoperative day 3 compared to that before surgery. Moreover, the autonomic nervous activity remained unchanged during the morning, and it was significantly lower during the night from postoperative day 1 until postoperative day 3 than before the surgery. These results suggest that there is a decrease in parasympathetic nervous activity during the nighttime postoperatively.

Nurses' lack of self-confidence in their own nursing skills is one of the main reasons that novice nurses leave the profession in Japan. Nursing education must help students gain self-confidence in their nursing skills in order to allow more novice nurses to stay in their profession. In this study, we evaluated whether confidence-weighted testing feedback actually improves students' self-confidence in their basic nursing skills. Confidence-weighted testing, which provides quantifiable results, might allow students to objectively assess their skill-related self-confidence. Sixty-seven first-year nursing students took two confidence-rating examinations on the knowledge and practical skills related to pulse and blood pressure measurement of immobile patients. Feedback was given to each participant after the first examination. After the first examination with confidence-weighted testing feedback, students showed higher levels of self-confidence in their practical skills, but not in knowledge. The improvement of self-confidence in practical skills suggests that there is still room for improvement in confidence-weighted testing feedback in knowledge. Further research is required to identify more effective feedback methods to improve students' self-confidence levels in knowledge using the results of confidence-weighted testing.

Madelung's disease is a rare disorder characterized by multiple, symmetric fatty tissues. The patient, 72-year-old man was admitted to our hospital for abdominal surgery for liver cancer. He had extreme fatty accumulations involving head and neck. We expected difficult airway because of his fatty tissues, and we perfomed awake intubation by Airway Scope. We confirmed the airway by using tube exchanger at extubation. We should choose a proper airway management technique to reduce the incidences of airway complications.

To provide patients with effective self-management education that takes their lifestyle into account, medical personnel need to provide education and evaluation of self-management behaviors which patients can apply to their daily life.This study aimed to assess the reliability and validity of the evaluation scale for self-management behavior related to physical activity of patients with coronary heart disease (ES-SMBPA-CHD).Outpatients with coronary heart disease (n = 76) completed a self-administered questionnaire supported by a previous study of ours. The ES-SMBPA-CHD was divided into two domains, the first dealing with self-management behavior to enhance physical activity in daily life and the second with behavior to maintain the level of physical activity. Factor analysis showed that the first part comprised four factors and the second five. The ES-SMBPA-CHD was associated with the International Physical Activity Questionnaire (IPAQ) subscales and activity energy expenditure (measured by Lifecorder EX). Cronbach's α coefficient was between 0.71 and 0.90. The intraclass test-retest correlation coefficient of the subscale was between 0.75 and 0.93.The ES-SMBPA-CHD is reasonably reliable and valid and is expected to prove useful for the assessment of patients' self-management behavior and for individualized instruction.

PURPOSE. We aimed to identify the cues of expert nurses and validate the cue information on the defining characteristics for a nursing diagnosis of ineffective self-management of fluid and dietary restrictions in dialysis therapy in Japan. METHODS. We used qualitative interviews and two-round Delphi studies. FINDINGS. The expert nurses regarded four signs of unmaintained fluid and dietary restrictions as major defining characteristics and nine other cues as minor defining characteristics. CONCLUSIONS. Expert nurses in dialysis therapy regard symptoms of health behavior as major cues for nursing diagnosis of ineffective self-management of fluid and dietary restrictions in dialysis therapy. IMPLICATIONS FOR NURSING PRACTICE. Verification of the clinical validity and development of a specific, clinically useful database on nursing diagnoses are required.

【目的】心不全患者が自分自身の体調変化を把握し，増悪の兆候を早期発見するための支援において，セルフモニタリングは重要な概念であるが，統一した見解はない．そこで，心不全患者への支援に資するためにセルフモニタリングの概念を明らかにした．【方法】Rodgersら（2000）の概念分析法を参考に概念を特定した．【結果】31件の文献を分析した結果，心不全患者のセルフモニタリングは，身体症状の変化，身体活動の変化，体調管理の状況をとらえることであり，概念の属性は「自覚」「測定」「解釈」という3つの側面で構成されていた．概念の先行要因には「知識」「技術」「関心」が存在し，帰結として「適切なセルフマネージメント」と「QOLの改善」が認められた．【結論】今回抽出された新しい概念は，心不全患者のセルフモニタリングを強化する看護支援の基盤として活用できることが示唆された．

非体外循環下冠動脈バイパス術(off-pump coronary-artery bypass grafting, off-pump CABG)術後に原因不明の強い全身性炎症を示し多臓器障害を呈したが,大量のコルチコステロイド投与により劇的に改善した症例を経験したので報告する。症例は72歳男性,既往症は高血圧,59歳時にCABG,70歳時に腹部大動脈瘤に対して人工血管置換術を受けた。今回増悪する狭心症に対してoff-pump CABGを受けたが,術後3日目より高熱,白血球増多,CRP高値を呈し,ショック,腎不全,高ビリルビン血症を合併した。アレルギー性疾患,感染症は否定的であった。術後12日目に,炎症の治療目的で,メチルプレドニゾロン500mgを3日間投与したところ,発熱,高炎症,多臓器障害は速やかに改善した。メチルプレドニゾロンの投与期間は25日間,その後,術後42日目に無事転棟となった。敗血症,ARDSなどの重症患者に対する高用量ステロイド投与による予後改善は現在否定されているが,今回のように全身性炎症状態のみが病態をなしている場合には有効でありうると考えた。

This study was conducted to elucidate factors that influence the self-evaluation of physical condition and perception of difficulties of life in ulcerative colitis patients. A survey and clinical examination were carried out in 171 outpatients with ulcerative colitis. Self-evaluation of physical condition was assessed according to a five-grade system. Perception of difficulties of life was assessed using a scale developed by the authors and others. Physical condition of patients was assessed according to their disease state, disease symptoms, and nutritional state. Additional related factors such as mental condition, demographic attributes, and psychosocial states were also investigated. Multiple regression analyses was used to assess the relationships among variables and showed that perception of difficulties of life and disease symptoms were the main explanatory factors for the self-evaluation of physical condition. Perception of difficulties of life was comprised of physical and mental conditions, the latter being further influenced by the patients' psychosocial state.

総合集中治療部で治療を要した産科患者の頻度,原因,転帰を調査し,産科重症患者の内容を分析した。1985～1996年に当院集中治療部に入室した産科患者は40名で,頻度は同時期の全ICU入室患者数の0.17%であった。入室理由は産科的合併症によるものが75%,内科疾患合併が25%で,主たる産科合併症は妊娠中毒症,分娩後出血,胎盤早期剥離であった。入室経路で比較すると,転送患者は院内患者に比し入室時のAPACHE IIスコア,妊娠中毒症の重症度,濃厚治療を要した合併症率が有意に高く,ICU在室日数も有意に長かった。40症例中26症例(65%)が1日でICUを退室し,死亡は羊水塞栓の1症例のみであった。産科重症患者は迅速かつ適切な処置を行えば予後は良好であり,その意味で集中治療部の存在の意義は大きい。産前管理の重要性が再認識されたとともに,今後妊娠中毒症の解明により重症患者の頻度の軽減が期待される。

The perioperative management of pheochromocytoma is challenging for anesthesiologists and persistent hypotension secondary to cathecholamine depletion after tumor resection can be refractory to treatment. A 64-year-old man underwent right adrenalectomy for treatment of massive pheochromocytoma. Doxazosin administration was started and increased gradually to 12 mg daily. He was premedicated with doxazosin on the day of the surgery. Induction was uneventful but there was a sudden increase of blood pressure with tachycardia on handling of tumor which was controlled by intravenous remifentanil, landiolol, diltiazem, and magnesium sulfate. With dissection of the tumor, the blood pressure dropped to 65/40 mmHg, which was resistant to fluid and cathecholamine treatment. After commencement of low dose vasopressin administration (two boluses of 0.08 U followed by 1.6 U x hr(-1)), blood pressure gradually recovered to normal ranges. Low dose vasopressin can be safely used to treat postadrenalectomy hypotension and also can reduce the cathecholamine dose.

Aims To investigate the effect of a computer-supported indirect-form lifestyle-modification program using Lifestyle Intervention Support Software for Diabetes Prevention (LISS-DP), as a clinically feasible strategy for primary prevention, on diet and physical activity habits in adults with a family history of type 2 diabetes. Methods This was a two-arm, randomized controlled trial: (1) lifestyle intervention (LI) group (n = 70); (2) control (n = 71). Healthy adults aged 30–60 years with a history of type 2 diabetes among their first-degree relatives were recruited. LI group received three times of lifestyle intervention using LISS-DP during six-month intervention period via mail. Results Lifestyle intervention group showed significantly greater decrease in energy intake six months after baseline, compared to control (−118.31 and −24.79 kcal/day, respectively, p = 0.0099, Cohen's d = 0.22), though the difference disappeared 1 year after from baseline. No difference was found in physical activity energy expenditure. Conclusions A computer-based, non-face-to-face lifestyle intervention was effective on dietary habits, only during the intervention period. Further examination of the long-term effects of such intervention and physical activity is required.

Unroofed coronary sinus (URCS) is a rare cardiac anomaly, in which communication occurs between the coronary sinus (CS) and the left atrium (LA) because of partial or complete absence of the CS roof. A 30-year-old woman was scheduled for surgical closure of atrial septal defect, mitral valve repair and tricuspid annuloplasty. The intraoperative transesophageal echocardiography (TEE) revealed left-to-right shunt between the CS and the LA. The three-dimensional (3D) TEE confirmed the diagnosis of partially URCS. This defect was repaired with a pericardial patch. In this case, the 3D images of URCS, which were a helpful supplement to the 2D images, providing better visualization of the wall defect and more information regarding the size and location of the defect. The combined use of 2D and 3D images provides valuable information to aid in understanding the anatomy and morphology of this rare anomaly.

Right thoracotomy is an alternative surgical technique for mitral valve reoperation. The purpose of this study is to determine whether right thoracotomy for mitral valve reoperation affects its perioperative outcomes and complications.We investigated the perioperative events in consecutive mitral valve reoperations between January 2006 and November 2009. Demographic, intraoperative and postoperative data were collected and analyzed retrospectively.Five right thoracotomy cases and 22 repeated sternotomy cases were included. Thoracotomy group needed more platelet transfusion (median, 20 units in thoracotomy; 10 units in sternotomy; P=0.047). We had a higher frequency of adrenaline administration (60% in thoracotomy; 4.6% in sternotomy; P=0.005) and needed more doses of dobutamine in thoracotomy group (median, 16.0 microg x kg(-1) x min(-1) in thoracotomy ; 7.5 microg x kg(-1) x min(-1) in sternotomy; P=0.037) to wean them from cardiopulmonary bypass. Right thoracotomy did not reduce cardiopulmonary bypass time (median, 265 min in thoracotomy ; 199 min in sternotomy; P=0.126). We experienced two serious complications requiring reoperation in thoracotomy group, but diagnosed them with intraoperative transesophageal echocardiography.When we choose right thoracotomy for mitral valve reoperation, we should prepare more blood products and inotropic agents and should evaluate cardiac function by using intraoperative transesophageal echocardiography.

To describe the illness experience of patients living with arrhythmia and implantable cardioverter defibrillator (ICD) and evaluate their experience after implantation of the device for gaining insight on care suitable for their condition.In this qualitative descriptive study, we conducted semi-structured interviews of 22 outpatients who were visiting certified implant facilities.Three categories and seven subcategories emerged from the interviews. The ICD patients were (1) Bewilderment Stemming from Arrhythmia and ICD Implant, (2) Facing the Reality of Arrhythmia, the ICD and Being Able To Continue Life, and (3) Giving Meaning to Living With Arrhythmia and an ICD. The ICD patients first experience bewilderment in the form of [Uncertainty about One's Own Bodies], [Fear of Arrhythmia Ending My Life], and [Dissatisfaction with Unforeseen Results of the ICD]. After discharge from the hospital following ICD implantation, they slowly resumed their own lifestyles and [Facing the Reality of the ICD and Being Able to Continue Life] and [Confirming and Managing Lifestyle Activities]. As they recognized, objectified, and faced changes in their lifestyles, they began to practically see themselves as living with arrhythmia which required ICD-aided treatment, [Giving Meaning to One's Illness] and [Recognition of One's Disease]. And so, they reknit their lives integrated with arrhythmia and an ICD. We expressed these results in a schematic model as "Learning to Live with Arrhythmia and the ICD".These results can be used to provide a perspective for assessing care to help patients adapt to life after ICD implantation.

Nurses' lack of self-confidence in their own nursing skills is one of the main reasons that novice nurses leave the profession in Japan. Nursing education must help students gain self-confidence in their nursing skills in order to allow more novice nurses to stay in their profession. In this study, we evaluated whether confidence-weighted testing feedback actually improves students' self-confidence in their basic nursing skills. Confidence-weighted testing, which provides quantifiable results, might allow students to objectively assess their skill-related self-confidence. Sixty-seven first-year nursing students took two confidence-rating examinations on the knowledge and practical skills related to pulse and blood pressure measurement of immobile patients. Feedback was given to each participant after the first examination. After the first examination with confidence-weighted testing feedback, students showed higher levels of self-confidence in their practical skills, but not in knowledge. The improvement of self-confidence in practical skills suggests that there is still room for improvement in confidence-weighted testing feedback in knowledge. Further research is required to identify more effective feedback methods to improve students' self-confidence levels in knowledge using the results of confidence-weighted testing.

To produce a simple food questionnaire for estimating total energy intake and intake of three major nutrients which medical or health care staff such as nurses can rapidly use for the determination of health guidance for individuals. The study group comprised 116 normal healthy subjects (mean age ± S.D. = 40.0 ± 17.8 years), 76 women and 40 men. Using findings based on our previous research and experiences and the simple food questionnaire (MHW-FQ) that the "Kenkoh Shihyoh Sakutei Iinkai" established by the then Ministry of Health and Welfare developed in 1975, we produced a modified version of the MHW-FQ and named it M-MHW-FQ. The study presented here was conducted for the statistical determination of the usefulness of M-MHW-FQ. M-MHW-FQ yielded much better results than MHW-FQ as evidenced by improved correlation coefficients, which ranged between 0.56 and 0.75. The findings showed that, despite its simplicity, M-MHW-FQ yielded relatively accurate results and was satisfactory for the rapid estimation of total energy intake including that of three major nutrients. This study provides evidence that our simple questionnaire, M-MHW-FQ, is useful for the rapid estimation of individual total dietary energy intake and nutrient balance. We expect that our questionnaire can make a significant contribution to an improvement in lifestyle-related diseases.

Many chronic heart failure patients are hospitalized repeatedly because many of them are still uncertain about the methods necessary for managing their own health. "Self-monitoring" is a useful concept for breaking through this vicious cycle. However, there are no suitable tools to measure aspects of self- monitoring. This study aimed at the development of an evaluation scale for self-monitoring by patients with chronic heart failure based on the concept of self-monitoring. Outpatient with chronic heart failure completed a self-administered scale comprises 2 domains and covers 38 items. Domain 1 deals with "awareness" and "measurement" of aspects of self-monitoring, domain 2 with "interpretation" of aspects of self-monitoring. The reliability and validity of this scale were thoroughly evaluated. Of the 167 patients asked to participate in the study, 142 gave valid responses. Factor analysis showed that the domain1 comprised six factors (21 items) and the domain2 four factors (16 items). Cronbach's α coefficient was 0.91 for domain1, 0.89 for domain2. The intra-class correlation coefficient of total score was 0.74 for domain1, 0.67 for domain2. Concurrent validity with the Heart Failure Self-care Behavior Scale was demonstrated. The scale is reasonably reliable and valid, and was proved to be useful for assessing conditions related to patient self-monitoring. Since it has become an indicator that shows to what degree patients can perceive their own health status, and nurses have been utilizing it to provide individual support to reduce the risks of exacerbated heart failure.

We aimed to identify the cues of expert nurses and validate the cue information on the defining characteristics for a nursing diagnosis of ineffective self-management of fluid and dietary restrictions in dialysis therapy in Japan.We used qualitative interviews and two-round Delphi studies.The expert nurses regarded four signs of unmaintained fluid and dietary restrictions as major defining characteristics and nine other cues as minor defining characteristics.Expert nurses in dialysis therapy regard symptoms of health behavior as major cues for nursing diagnosis of ineffective self-management of fluid and dietary restrictions in dialysis therapy.Verification of the clinical validity and development of a specific, clinically useful database on nursing diagnoses are required.

Relatives of type 2 diabetic patients are at a high risk of developing type 2 diabetes and should be regarded as target of intervention for diabetes prevention. However, it is usually hard to motivate them to implement preventive lifestyle changes, because of lack of opportunity to take advises from medical professionals, inadequate risk perception, and low priority for preventive behavior. Prevention strategy for them therefore should be highly acceptable and suited for them. The parallel, three-group trial is now being conducted to investigate the effects of genetic counseling and/or a computerized behavioral program on the prevention of type 2 diabetes in that population. The preventive strategies used in this study could provide a novel solution to the numbers of genetically high-risk individuals, if found to be effective. The objective of this paper is to describe the background, protocol, and baseline patient characteristics of the trial.

Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB).We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups.There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups.Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

The importance of collaborative practice and its education have been widely reported globally and nationally. At a local level, staff members’ experiences in the field after a natural disaster and their clinical work contributed significantly to the development of an interprofessional education/learning (IPE/L) program at Kobe University. From the first pilot classes in 2002, an IPE program evolved. This program is now fully integrated into the 4-year undergraduate curriculum at the Faculty of Health Sciences and into the 6-year curriculum of the School of Medicine. Student learning in this IPE/L program is interactive, experientially based, and predominantly conducted in interprofessional group settings.

We experienced the combustion of the endotracheal tube during a bronchoscopic potassium titanyl phosphate laser resection of an intratracheal metastatic tumor. Some preventive precautions have been reported, however, none of them are absolutely perfect. We report the rare occurrence of tracheal tube ignition, preventive measures and treatment strategies for the resultant airway burn.

To establish effective dietary self-management behavior for type II male and female diabetics, by focusing on how dietary intake and dietary self-management affect control indices of type II diabetics.The study group comprised 170 type II diabetics, 93 men (mean age, 63.1+/-8.8 years old) and 77 women (mean age 63.4 +/- 10.2 years old). The final analyses of data collected from subjects comprised three control indices of type II diabetics, several factors related to control indices, and several items on a dietary self-management behavior questionnaire. Multiple regression analyses used control indices as dependent variables, and related factors as independent variables. Multiple regression analyses were also used for the relationships between dietary intakes as dependent variables and dietary self-management factors as independent variables.Males showed a significant correlation between total energy intake per standard body weight per day and body mass index, and a significantly positive correlation between body mass index and waist circumference. Carbohydrate intake was significantly related to HbA1c. Other results showed characteristic relationships between various questionnaire items and "total energy intake, lipids intake, and carbohydrate intake", respectively. Females showed significant correlation between carbohydrate intake and both body mass index and waist circumference, as well as characteristic correlations between various questionnaire items and both reductions and increases in carbohydrate intake.Our study discloses significant differences in dietary self-management behavior between males and females with type II diabetes. We anticipate that educational support using findings of our study can make a significant contribution to improvement in control indices of type II diabetics.

OBJECTIVE—The aim of this study was to assess the reliability and validity of an evaluation scale for self-management behavior related to physical activity of type 2 diabetic patients (ES-SMBPA-2D). RESEARCH DESIGN AND METHODS—Outpatients with type 2 diabetes (n = 146) completed a self-administered questionnaire supported by a semistructured interview based on a literature review. The content, factor, and concurrent validity and internal consistency and reproducibility of the scale were analyzed. Pearson’s correlation coefficients for the ES-SMBPA-2D and International Physical Activity Questionnaire (IPAQ) subscale scores were calculated to evaluate the concurrent validity. RESULTS—The ES-SMBPA-2D was divided into two parts, the first dealing with self-management behavior to enhance physical activity in daily life and the second with behavior to maintain the level of physical activity. Factor analysis showed that the first part comprised four factors and the second five. The ES-SMBPA-2D correlated with the IPAQ subscales. Cronbach’s α coefficient was between 0.56 and 0.90, and the intraclass test-retest correlation coefficient of the subscales was between 0.60 and 0.88. CONCLUSIONS—The ES-SMBPA-2D is reasonably reliable and valid and is expected to prove useful for the assessment of patients’ self-management behavior and for individualized instruction.

o a o M o a f o i DIOPATHIC HYPEREOSINOPHILIC syndrome (HES) is a rare systemic disease characterized by unexplained persisent eosinophilia associated with multiple-organ damage. It is hought that inflammation mediated by eosinophils and micromboli cause organ damage.1 The prognosis is correlated with ardiac damage, which includes restrictive cardiomyopathy, alvular dysfunction, and thromboembolic events.2,3 Although ome cases of recurrent prosthetic valve thromboses have been eported,4,5 experience in the perioperative management of ardiac valvular surgery in patients with HES is limited.6,7 In this report, 2 patients with HES undergoing cardiac surery are described. One of them developed severe prosthetic alve insufficiency and died. The authors also review the litrature with regard to the perioperative management of patients ith HES.

A 65-year-old man received general anesthesia for extended esophagectomy with 3-field lymph node dissection. Although he was without many risk factors for stroke except smoking, chest computed tomography performed preoperatively showed a small calcification at the origin of the left subclavian artery on the aortic arch. The anesthetic course was uneventful. On the first postoperative day, when the patient awoke from sedation, he presented with left conjugate deviation of the eyes and right hemiparesis. Immediate computed tomography scanning revealed cerebral infarction in the area of the left middle cerebral artery associated with hyper density indicating a thrombus. Both transthoracic echocardiography and carotid ultrasonography were performed to determine the cause of stroke. As a result, severe atheromatous stenosis of the left internal carotid artery was noticed, while there was neither thrombus nor shunt in the heart. Intraoperative cerebral emboli during surgical manipulation of the carotid artery were strongly suspected as a possible cause of the stroke. Preoperative carotid screening by ultrasonography may be advocated to identify such a patient as the present case with occult carotid atherosclerosis at risk for a subsequent stroke.