Objectives: At present, the dose conversion ratio for a continuous intravenous infusion of fentanyl (CIV) and fentanyl transdermal patches (TP), which are widely used in Japan, is not based on the results of clinical studies in Japanese patients. Studies comparing serum fentanyl concentrations in patients with cancer pain treated by TP showed large differences between Japanese patients and those in other countries. We therefore studied the dose conversion ratio in Japanese patients. Methods: From October 2003 through October 2008, we extracted information on all patients with gastrointestinal cancer who underwent rotation from CIV to TP in the gastrointestinal ward of Kitasato University East Hospital. We selected patients in whom the daily dose of CIV or TP (i.e., the basic dose) was unchanged for 10 days after rotation and the difference in the number of rescue doses (per day) as compared with immediately before rotation was 1 or less on at least 3 consecutive days. All TP preparations used in this study were reservoir-type. Regression lines were plotted on the basis of the relation of “the basic released dose of TP” to “the basic prescribed dose of CIV,” and the dose conversion ratio was calculated. Results: 47 patients underwent opioid rotation, and 11 of them satisfied the eligibility criteria. Eleven patients were studied. The following regression equation was obtained: Y=1.0227X+1.0103, r²=0.9188, indicating a strong correlation. The dose conversion ratio of CIV to TP (released dose) derived by regression analysis was 1:1. Conclusions: Our results obtained in Japanese patients will allow dose conversion at the time of opioid rotation from CIV to TP to be more appropriately performed.

A 66-year-old man with an unknown medical history developed chest pain and a diagnosis of acute myocardial infarction (AMI) was given by his physician. Percutaneous coronary intervention was performed in the left anterior descending artery. Echocardiography revealed ventricular septal perforation (VSP) ; therefore, the patient was transferred to our hospital. After admission, his platelet count dropped rapidly during heparin administration, and left ventricular thrombosis and deep vein thrombosis were noted, raising a suspicion of heparin-induced thrombocytopenia (HIT). To establish cardiopulmonary bypass, argatroban alone was insufficient to prolong the Powered by Editorial Manager^® and ProduXion Manager^® from the Aries Systems Corporation activated clotting time (ACT) ; thus, nafamostat mesilate was also used for coronary artery bypass grafting and surgical repair of VSP. It took many hours to normalize the ACT, requiring re-exploration for excessive bleeding. On the 37th postoperative day, the patient was transferred to another hospital. We performed cardiac surgical procedures using argatroban in a patient who developed HIT during the course of VSP following AMI ; however, we had difficulty in controlling the ACT. Since, to the best of our knowledge, there are no previous studies reporting surgical case of VSP complicated by HIT, we present this case with a review of the relevant literature.

An 88-year-old woman presented at a local hospital with a left femoral pulsatile mass. CT revealed saccular aneurysms with irregular intima in the descending thoracic aorta, the right common femoral artery and the left superficial femoral artery. They were 60 mm, 30 mm, and 25 mm in diameter, respectively. After referral to our hospital, multiple inflammatory aneurysms were strongly suspected by detailed examinations. Endovascular treatment including thoracic endovascular aortic repair and surgical replacement were performed by two-stage operations. After steroid therapy was started postoperatively, her c-reactive protein (CRP) value decreased. Nevertheless, the thoracic aortic aneurysm enlarged and she died due to hemorrhage. Multiple inflammatory aneurysms are extremely rare. We consider that appropriate steroid therapy and close follow-up are most important.

An 80-year-old man presented with a history of retrosternal gastric tube reconstruction for esophageal cancer. He experienced sudden chest pain, and temporarily lost consciousness, before being transferred to our hospital. Contrast-enhanced computed tomography revealed acute Stanford type A aortic dissection and a retrosternal gastric tube. We performed emergency operation using a median sternotomy approach. Before median sternotomy, we detected the gastric tube in the subxiphoid and suprasternal spaces. The anterior and right sides of the gastric tube were dissected bluntly from the posterior surface of the sternum and median sternotomy was performed. The gastric tube was mobilized to the left side and we were able to obtain the usual operative view for ascending aorta graft replacement. Intraoperatively, the gastric tube remained intact and uninjured. The patient was transferred to another hospital for rehabilitation on postoperative day 34.

Physicians expect nurses to be able to understand electrocardiographic (ECG) findings.However, many nurses have difficulty learning how to interpret ECGs.We suspect that the reason for such difficulty might be the nurses'mental responses to ECGs, rather than improper teaching methods.
1) We performed a questionnaire survey to investigate the mental responses to ECGs based on the responses of 197 experienced nurses and 43 new nurses and on an additional survey of 37 nurses who took ECG evaluation tests.
2) Almost all nurses recognized the necessity and importance of understanding ECG findings, and most wished to master ECGs.On the other hand, many nurses said that they disliked ECGs and did not feel competent interpreting ECGs.In particular, their perceived lack of competence in interpreting ECGs was greater than their dislike of ECGs.
3) The nurses'perceived lack of competence interpreting ECGs tended to result from feelings that developed during nursing school.Many nurses continued to have such feelings even after they began working.
4) Nurses with a poor understanding of ECGs reported many factors as being associated with their perceived lack of competence.In addition, such negative feelings toward ECGs (such as fear of making a mistake) made these nurses avoid ECGs.We believe that these feelings were likely a factor in why many nurses had difficulty mastering ECGs.
5) Nurses should be provided with appropriate ECG training that carefully considers the perceived incompetence and fear of many nurses regarding ECGs.

PURPOSE: To examine the effects of conservative and surgical treatments for nocturnal leg cramps in patients with lumbar spinal stenosis (LSS). Nocturnal leg cramps is frequently observed in patients with peripheral neuropathy. However, there have been few reports on the relationship between nocturnal leg cramps and LSS, and it remains unknown whether conservative or surgical intervention has an impact on leg cramps in patients with LSS. MATERIALS AND METHODS: The subjects were 130 LSS patients with low back and leg pain. Conservative treatment such as exercise, medication, and epidural block was used in 66 patients and surgical treatment such as decompression or decompression and fusion was performed in 64 patients. Pain scores and frequency of nocturnal leg cramps were evaluated based on self-reported questionnaires completed before and 3 months after treatment. RESULTS: The severity of low back and leg pain was higher and the incidence of nocturnal leg cramps was significantly higher before treatment in the surgically treated group compared with the conservatively treated group. Pain scores improved in both groups after the intervention. The incidence of nocturnal leg cramps was significantly improved by surgical treatment (p=0.027), but not by conservative treatment (p=0.122). CONCLUSION: The findings of this prospective study indicate that the prevalence of nocturnal leg cramps is associated with LSS and severity of symptoms. Pain symptoms were improved by conservative or surgical treatment, but only surgery improved nocturnal leg cramps in patients with LSS. Thus, these results indicate that the prevalence of nocturnal leg cramps is associated with spinal nerve compression by LSS.
Adult ; Aged ; Aged, 80 and over ; Decompression, Surgical ; Female ; Humans ; Leg/*pathology ; Low Back Pain/epidemiology/etiology ; Male ; Middle Aged ; Pain/*epidemiology/*etiology ; Prospective Studies ; Questionnaires ; Spinal Stenosis/*complications/*physiopathology/surgery

PURPOSE: The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI. MATERIALS AND METHODS: One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment. RESULTS: Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05). CONCLUSION: This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.
Adult ; Aged ; Aged, 80 and over ; Alprostadil/therapeutic use ; *Ankle Brachial Index ; Decompression, Surgical/methods ; Female ; Humans ; Low Back Pain/drug therapy/physiopathology/surgery/*therapy ; Lumbar Vertebrae/physiopathology/*surgery ; Male ; Middle Aged ; Pain/surgery ; Spinal Nerve Roots/physiopathology ; Spinal Stenosis/physiopathology/*surgery/*therapy ; Treatment Outcome

BACKGROUND: We aimed to estimate the prevalence of depressive symptoms as well as suicide-related ideation among Japanese university students during the stay-home order necessitated by the coronavirus disease 2019 pandemic in Japan, and offer evidence in support of future intervention to depression and suicide prevention strategies among college and university students. METHODS: The data for this cross-sectional study were derived from the Student Mental Health Survey conducted from May 20 to June 16, 2020 at a national university in Akita prefecture. Among the 5111 students recruited, 2712 participated in this study (response rate, 53%; mean age ± standard deviation, 20.5 ±3.5 years; men, 53.8%). Depressive symptoms were identified by using the Patient Health Questionnaire-9 (PHQ-9). RESULTS: The prevalence of moderate depressive symptoms based on a PHQ-9 score ≥10 and suicide-related ideation based on question 9 of PHQ-9 ≥1, which encompasses thoughts of both suicide and self-harm, was 11.7% and 6.7%, respectively. Multivariable logistic regression analyses showed that risk factors for depression included being a woman, smoking, alcohol consumption, and social network communication using either video or voice. For suicide-related ideation, alcohol consumption was the only risk factor. Exercise and having someone to consult about worries were associated with decreased risk of both depressive symptoms and suicide-related ideation. CONCLUSIONS Negative lifestyles of smoking and drinking, and being a woman, may be important risk factors for depressive symptoms, whereas exercise and having someone to consult about worries may be protective factors.
Adolescent ; Alcohol Drinking ; COVID-19/psychology* ; Cross-Sectional Studies ; Depression/epidemiology* ; Female ; Humans ; Japan/epidemiology* ; Logistic Models ; Male ; Multivariate Analysis ; Pandemics ; Risk Factors ; Smoking ; Students/psychology* ; Suicidal Ideation ; Surveys and Questionnaires ; Young Adult