Purpose: In Japan, only a few studies reported self-management systems of narcotic drugs among hospitalized patients. Our purpose was to develop a self-management system for patients and assess its effectiveness. Methods: Based on the results of a questionnaire administered to our hospital medical staff, methods of selecting eligible patients and methods of self-management of narcotic drugs were determined by a multi-professional team. Selection criteria for eligible patients were: 1) satisfactory results on assessment of the patient's ability to self-manage orally-administered drugs; 2) satisfactory results on assessment of the patient's ability to self-manage narcotic drugs; 3) physician's consent was obtained; and 4) the patient wanted to participate in this program. After the period of self-management of drug administration, questionnaires were distributed to the patients and medical staff in the general ward. Results: One hundred hospitalized patients used narcotic drugs between April 2008 and March 2009. Among them, 26 patients met the criteria for self-management of narcotic drugs, and 20 voluntarily participated in the program. There were no reports of missing or stolen drugs. There were no reports of administration of incorrect dose of the drug during the self-management period (average 15.0 days). Ninety-four percent of the self-managing patients provided positive feedback about self-management of narcotic drugs, such as mental stability by having drugs on hand and no problems in self-management. Seventy-five percent of staff members answered that the self-management system of narcotic drugs should be continued. Conclusion: Our results suggest that this system of narcotic drug self-management is safe and appropriate. Palliat Care Res 2010; 5(1): 114-126

Pancreatic cancer is the fifth leading cause of cancer-related death in Japan. Surgical treatment is the effective way to achieve a long survival. Because of the development of surgical procedure and perioperative management, pancreatic surgery becomes safer. However, it still includes a certain number of morbidities and mortalities. It is important to perform safe operation for long survival. We herein introduce our operative procedure for pancreatic surgery including pancreaticoduodenectomy (PD) and distal pancreatectomy. In patients undergoing PD, leakage from the pancreatic anastomosis remains an important cause of morbidity and contributes to prolonged hospitalization and mortality. Recently, a new end-to-end pancreatojejunostomy technique without the use of any stitches through the pancreatic texture or pancreatic duct has been developed. In this novel anastomosis technique, the pancreatic stump is first sunk into deeply and tightened with a purse string in the bowel serosa. We modified this method in an end-to-side manner to complete the insertion of the pancreatic stump into the jejunum, independent of the size of the pancreas or the jejunum. Since April 2013, we have performed this new anastomosis technique in 36 patients. The breakdown of preoperative diagnosis of 36 patients were 13 pancreatic cancers, 8 extrahepatic bile duct cancers, 7 intraductal papillary mucinous neoplasms and so on. Of 36 PD, 32 were subtotal stomach preserving PD (SSPPD), and the rest were SSPPD combined with left hemihepatectomy or distal pancreatectomy, and middle pancreatectomy. The concentration of amylase in discharged fluid through an abdominal drain decreased day by day. According to the ISGPF definition, pancreatic fistula (PF) was observed in 4 patients (11%). Of 4, only 1 case had grade C PF. This case had a hemorrhage from pancreatic cut end. This occurred probably because the pancreatic cut end was not compressed by the intestinal wall with this technique. This case had reoperation and the hemostasis of pancreatic cut end was secured. The other severe complications were not observed. This new method can be performed safely and is expected to reduce the occurrence of leakage from PD. The development of PF following distal pancreatectomy is an unsolved problem. We introduce a simple technique, the parallel suturing technique, which prevents severe PF by hand-sewn closure of the pancreatic stump. After standard distal pancreatectomy in the described cases, the main pancreatic duct was secured. The stump of the pancreatic remnant was closed with three nonabsorbable monofilament sutures. The three sutures were positioned about 3 mm proximal to the cut end of the pancreas and tied parallel to the pancreatic stump. Ascites fluid was collected through a drain tube, and its concentration of amylase was measured on days 1, 2, 3, and 4 postoperatively. PF was diagnosed according to the ISGPF classification. On postoperative day 4, three patients were categorized as having grade A PF, six were diagnosed with no PF, and the drain tubes of the remaining three were removed on day 3. This simple technique may effectively lighten the severity of PF following distal pancreatectomy. It may have a particular advantage in patients with a wide pancreatic stump.

BACKGROUND: In daily clinical practice, it is essential to properly evaluate the postoperative sliding distance of various femoral head fixation devices (HFD) for trochanteric fractures. Although it is necessary to develop an accurate and reproducible method that is unaffected by inconsistent postoperative limb position on radiography, few studies have examined which method is optimal. Therefore, the purpose of this study is to prospectively compare the accuracy and reproducibility of our four original methods in the measurement of sliding distance of the HFD. METHODS: Radiographs of plastic simulated bone implanted with Japanese proximal femoral nail antirotation were taken in five limb postures: neutral, flexion, minute internal rotation, greater external rotation, and flexion with external rotation. Orthopedic surgeons performed five measurements of the sliding distance of the HFD in each of the flowing four methods: nail axis reference (NAR), modified NAR, inner edge reference, and nail tip reference. We also assessed two clinical cases by using these methods and evaluated the intraclass correlation coefficients. RESULTS: The measured values were consistent in the NAR method regardless of limb posture, with an even smaller error when using the modified NAR method. The standard deviation (SD) was high in the nail tip reference method and extremely low in the modified NAR method. In the two clinical cases, the SD was the lowest in the modified NAR method, similar to the results using plastic simulated bone. The intraclass correlation coefficients showed the highest value in the modified NAR method. CONCLUSIONS: We conclude that the modified NAR method should be the most recommended based on its accuracy, reproducibility, and usefulness.
*Bone Nails ; *Dimensional Measurement Accuracy ; Fracture Fixation, Intramedullary/instrumentation/*methods ; Hip Fractures/*surgery ; Prospective Studies ; Reproducibility of Results

Objective：Although prediction of functional recovery after lacunar infarction is challenging, quantitative evaluation of brain imaging may be promising. In this article, we investigate association of the amount of corticospinal tract (CST) injury on Computed Tomography (CT) and functional recovery of lacunar infarction in the corona radiata.Methods：In 24 patients with lacunar infarction of the corona radiata, we investigated association of the amount of virtual CST injury with upper and lower limb motor function at 90 days after the stroke onset. The optimal area of the virtual CST to predict motor function was also determined. Finally, we evaluated whether the quantitative CST injury predicted practical motor function regarding activities of daily living.Results：The amount of virtual CST injury, evaluated with Hounsfield unit value of CT, was significantly associated with upper and lower limb function at 90 days after stroke onset. Among them, 6 mm radius CST circle for upper limb had the highest regression coefficient to predict Brunnstrom stage for the upper extremity (R2＝0.69), grip strength (R2＝0.52) and Simple Test for Evaluating Hand function (R2＝0.75). Also, 7 mm radius CST circle for lower limb had the highest regression coefficient to predict Brunnstrom stage for the lower extremity (R2＝0.51), weight bearing index (R2＝0.53) and Berg Balance Scale (R2＝0.52). These virtual CSTs predicted practical function including practical upper limb and ambulation.Conclusion：Quantitative evaluation of CST on CT predicted functional recovery after lacunar infarction of the corona radiata.

Objective：Although prediction of functional recovery after lacunar infarction is challenging, quantitative evaluation of brain imaging may be promising. In this article, we investigate association of the amount of corticospinal tract (CST) injury on Computed Tomography (CT) and functional recovery of lacunar infarction in the corona radiata.Methods：In 24 patients with lacunar infarction of the corona radiata, we investigated association of the amount of virtual CST injury with upper and lower limb motor function at 90 days after the stroke onset. The optimal area of the virtual CST to predict motor function was also determined. Finally, we evaluated whether the quantitative CST injury predicted practical motor function regarding activities of daily living.Results：The amount of virtual CST injury, evaluated with Hounsfield unit value of CT, was significantly associated with upper and lower limb function at 90 days after stroke onset. Among them, 6 mm radius CST circle for upper limb had the highest regression coefficient to predict Brunnstrom stage for the upper extremity (R2＝0.69), grip strength (R2＝0.52) and Simple Test for Evaluating Hand function (R2＝0.75). Also, 7 mm radius CST circle for lower limb had the highest regression coefficient to predict Brunnstrom stage for the lower extremity (R2＝0.51), weight bearing index (R2＝0.53) and Berg Balance Scale (R2＝0.52). These virtual CSTs predicted practical function including practical upper limb and ambulation.Conclusion：Quantitative evaluation of CST on CT predicted functional recovery after lacunar infarction of the corona radiata.

OBJECTIVESWith greater concern for efficient resource allocation and profiling of medical care, a case-mix classification was applied for the per-diem payment system in Japan. Many questions remain, one of which is the role of comorbidity and complication (CC) in grouping logic. We examined the association of the number of CC with the length of hospital stay (LOS) and hospital mortality as well as the proportion of LOS high outliers in 19 major diagnostic categories (MDCs).

METHODSThis study was a secondary data analysis embedded in a government research project, including anonymous claims and clinical data during a 4-month period from July 2002. Every 19 MDC, LOS, hospital mortality or proportion of LOS high outliers was compared by the number of CC and presence of any procedures.

RESULTSFrom 82 special function hospitals, 241,268 patients were enrolled in this study. Among all patients, 50.5% were identified without any CCs, 32.4% with one or two, 13.4% with three or four, and 3.7% with over five CCs. The overall mean LOS was 22.15 days and hospital mortality 26.05 cases per 1,000 admissions. In any MDC, LOS and the proportion of outliers increased as the number of CC rose. The mortality rate increased prominently in the respiratory system and the hematology system.

CONCLUSIONSThis study demonstrated that the occurrence of more CC caused longer LOS and higher mortality in some major disease categories. Further study will clarify the association of the weighted CC with resource use through controlling procedures specific for MDC.

Severe pain from mucositis resulting from concomitant chemoradiotherapy (CCRT) is commonly treated with opioid analgesics. However, the period of use of opioid analgesics differs among individuals. We performed a retrospective cohort study of 46 patients who were treated with long-term opioid analgesics after CCRT for head and neck cancer. Among these patients, opioid analgesics were used for a median of 30 days. A comparative study was conducted between patients with long-term use of strong opioid analgesic drugs and those with short-term use. A significantly prolonged use of opioid analgesic agent was associated with cetuximab use (TPF vs. S-1 vs. Cmab, 35.0 vs. 44.1 vs. 180.7, p≤0.001). There were no psychiatric symptoms such as dependence and delirium. When patient background and chemotherapy selection are known, the possibility of severe oropharyngeal mucositis and the potential need for long-term opioid analgesics can be evaluated. Consideration of reduction or discontinuation according to pain after the end of treatment is important.

Purpose: The albumin-to-globulin ratio (AGR) is a recognized chronic inflammation marker. No evidence regarding the relationship between AGR level and ulcerative colitis (UC) exists. The aim of this study was to evaluate the association between AGR and clinical outcomes among Japanese subjects with UC. Methods: The study subjects consisted of 273 Japanese individuals with UC. AGR was divided into 4 categories (low, moderate, high, and very high). The definition of complete mucosal healing (MH) was based on the Mayo endoscopic subscore of 0. Clinical remission (CR) was defined as no rectal bleeding and no abnormally high stool frequency (<3 times per day). Results: The percentage of MH was 26.4%. High AGR and very high AGR were significantly positively correlated with CR (adjusted odds ratio [OR], 5.85; 95% confidence interval [CI], 2.52–14.18 and adjusted OR, 4.97; 95% CI, 2.14–12.04) and complete MH (adjusted OR, 4.03; 95% CI, 1.56–11.51 and adjusted OR, 5.22; 95% CI, 1.97–14.89), respectively after adjustment for confounding factors (P for trend=0.001). Only in the low C-reactive protein (CRP) group (≤0.1 mg/dL), very high AGR was significantly positively correlated with complete MH but not CR (adjusted OR, 4.38; 95% CI, 1.06–21.77; P for trend=0.017). In the high CRP group, no correlation between AGR and complete MH was found. Conclusion Among Japanese patients with UC, AGR may be independently positively correlated with complete MH. In particular, among UC patients with low CRP, AGR might be a useful complementary marker for complete MH.

Objective: To implement early rehabilitation interventions by physical therapists is recommended. However, the effectiveness of early rehabilitation for severe coronavirus disease 2019 (COVID-19) patients in the prevention of post-intensive care syndrome (PICS) is unclear. We analyzed a multicenter prospective observational study (Post-Intensive Care outcomeS in patients with COronaVIrus Disease 2019) to examine the association between early rehabilitation interventions and PICS physical impairment. Methods: An analysis was performed on COVID-19 patients who were admitted to intensive care units (ICUs) between March 2020 and March 2021, and required mechanical ventilation. The primary outcome was the incidence of PICS physical impairment (Barthel Index≤90) after one year. Multivariate logistic regression analysis was used to estimate the association between early rehabilitation interventions and PICS physical impairment by adjusting ICU mobility scale (IMS) during seven-day following ICU admission, and clinically relevant risk factors. Results: The analysis included 259 patients, 54 of whom developed PICS physical impairment one year later. In 81 patients, physical therapists intervened within seven days of ICU admission. There was no significant difference in mean IMS by day seven of admission between the early and non-early rehabilitation patients (0.70 and 0.61, respectively). Multivariate logistic regression analysis showed that early rehabilitation interventions were significantly associated with a low incidence of PICS physical impairment (odds ratio, 0.294; 95% confidence interval, 0.123–0.706; p=0.006). Conclusion Early rehabilitation interventions by physical therapists were an independent factor associated with the decreased development of PICS physical impairment at one year, even though early rehabilitation had no significant effect on IMS.

Objective: To implement early rehabilitation interventions by physical therapists is recommended. However, the effectiveness of early rehabilitation for severe coronavirus disease 2019 (COVID-19) patients in the prevention of post-intensive care syndrome (PICS) is unclear. We analyzed a multicenter prospective observational study (Post-Intensive Care outcomeS in patients with COronaVIrus Disease 2019) to examine the association between early rehabilitation interventions and PICS physical impairment. Methods: An analysis was performed on COVID-19 patients who were admitted to intensive care units (ICUs) between March 2020 and March 2021, and required mechanical ventilation. The primary outcome was the incidence of PICS physical impairment (Barthel Index≤90) after one year. Multivariate logistic regression analysis was used to estimate the association between early rehabilitation interventions and PICS physical impairment by adjusting ICU mobility scale (IMS) during seven-day following ICU admission, and clinically relevant risk factors. Results: The analysis included 259 patients, 54 of whom developed PICS physical impairment one year later. In 81 patients, physical therapists intervened within seven days of ICU admission. There was no significant difference in mean IMS by day seven of admission between the early and non-early rehabilitation patients (0.70 and 0.61, respectively). Multivariate logistic regression analysis showed that early rehabilitation interventions were significantly associated with a low incidence of PICS physical impairment (odds ratio, 0.294; 95% confidence interval, 0.123–0.706; p=0.006). Conclusion Early rehabilitation interventions by physical therapists were an independent factor associated with the decreased development of PICS physical impairment at one year, even though early rehabilitation had no significant effect on IMS.