Nurses' Attitudes, Practices, and Barriers to Assessing Symptoms of Discomfort in Mechanically Ventilated Patients: A Cross-Sectional Study.

Introduction: Critically ill patients experience various stressful symptoms of discomfort, including dyspnea, pain, and sleep disruption. Notably, ventilated patients have difficulty self-reporting discomfort symptoms. Nurses need to assess discomfort symptoms to alleviate them, but limited research exists on discomfort symptom assessment and management in critically ill patients. Objective: To identify the practices, attitudes, and barriers among nurses related to the assessment of discomfort symptoms in mechanically ventilated patients. Methods: Using a cross-sectional, descriptive study design, a web-based survey was conducted between May and June 2022 with critical care nurses sampled through Japanese academic societies and social networking services. The survey contained questions relative to the above-stated objective. Descriptive statistical analysis was performed without sample size calculation because of the descriptive and exploratory nature of this study. Results: There were 267 respondents to the questionnaire. The discomfort symptoms that nurses perceived as important to assess were pain (median 100 [interquartile range, IQR 90-100]), insomnia (99 [80-100]), and dyspnea (96.5 [75-100]). Most participants (89.8%) routinely assessed pain in mechanically ventilated patients using a scale; however, other discomfort symptoms were assessed by less than 40% (dyspnea [28.4%], fatigue [8.1%], thirst [13.1%], insomnia [37.3%], and anxiety [13.6%]). Two major barriers to assessing discomfort symptoms were lack of assessment culture within the intensive care unit and lack of knowledge of the relevant evaluation scales. Conclusions: Nurses were aware of the importance of using scales to assess the discomfort symptoms experienced by mechanically ventilated patients. However, except for pain, most nurses did not routinely use scales to assess discomfort symptoms. Barriers to routine discomfort symptom assessment included the lack of an assessment culture and the lack of knowledge of the assessment scales. Clinicians should be educated regarding the existence of validated rating scales and develop additional rating scales utilizable for minor discomforts in mechanically ventilated patients.

The Effect of the Postural Control Strategy on the Recognition Error of Center-of-Pressure Sway.

The purpose of this study was to examine the effect of postural control strategies on the recognition error (RE) of center-of-pressure (COP) sway forward based on perceived exertion. Participants were 43 middle-aged or elderly people. We measured the maximum COP sway forward (100% center-of-pressure distance(COP-D)), 60% and 30% COP-D of 100% COP-D based on perceived exertion, and participants were classified into the good balance group and bad balance group by RE. The RE and trunk and leg angles were evaluated during COP sway forward. Results showed that RE being significantly higher for 30% COP-D and the group with a larger RE had a significantly larger trunk angle. Therefore, they may have used hip strategy predominantly to perform postural control ability, not only maximum values, but also on perceived exertion.

Balloon-occlusion Retrograde Transvenous Obliteration Using Gadoteridol As an Alternative Contrast Agent in a Patient with Iodine Allergy.

A 70-year-old woman with liver cirrhosis presented with gastric varices and recurrent hepatic encephalopathy. Magnetic resonance imaging (MRI) showed a splenorenal shunt, and balloon-occluded retrograde transvenous obliteration (B-RTO) was indicated but could not be performed due to iodine allergy. We then performed B-RTO using gadoteridol, an MRI contrast medium, instead of iodine contrast and successfully occluded the shunt vessel. After the procedure, hepatic encephalopathy did not recur, and the size of the gastric varices was reduced. This experience may aid in the management of iodine-allergic patients requiring interventional radiological treatment.

Thoughts and attitudes toward disasters among Japanese patients with type 1 diabetes: A qualitative descriptive study.

AIM: The purpose of this study was to clarify the thoughts and attitudes of patients with type 1 diabetes during disasters. METHODS: We conducted a qualitative descriptive study. The participants were 10 adult patients with type 1 diabetes who were selected through purposeful sampling. None of them had experienced a disaster. Data were collected through semi-structured interviews. Thematic analysis was used to analyze the data. RESULTS: Type 1 diabetes patients described a variety of thoughts and attitudes regarding disaster and preparedness. Based on their experiences, 528 codes were extracted. The codes were categorized based on their patterns and similarities. Then, 11 sub-themes and three main themes were identified. The three main themes were (a) "being unprepared since one could not relate to disasters"; (b) "managing well with insulin and food"; and (c) "hiding the fact that one has diabetes." CONCLUSIONS: This study identified three important characteristics of the thoughts and attitudes of patients with type 1 diabetes toward disasters. These provide perspectives for education in pre-disaster preparation and support when disasters occur. Patients with type 1 diabetes are aware of the importance of insulin, food adjustment, and self-management on a daily basis. Therefore, it is necessary to educate them so that they can apply their knowledge in times of disaster. In addition, healthcare providers who provide support in times of disaster need to be aware that there are victims who cannot talk readily about their illness.

Pulse Amplitude Measured with a Portable Laser Doppler Flowmeter Is Useful for Screening of Dialysis Patients for Peripheral Arterial Disease: An Observational Study.

Objective: The objective of this study was to use a portable laser Doppler flowmeter (LDF) to measure the toe blood flow and pulse amplitude as a screening test for peripheral arterial disease (PAD) in dialysis patients and compare the diagnostic abilities of the aforementioned parameters measured using an LDF with those of the ankle-brachial index (ABI) and toe brachial index (TBI). Methods: The 14 patients in this retrospective study received maintenance hemodialysis (HD). We measured the blood flow and pulse amplitude on the ventral side of the first toe with a portable LDF while the patients were undergoing an HD session. The correlations between the blood flow/pulse amplitude in the toe and the ABI/TBI were examined. Results: Both the ABI and TBI had a strong correlation with pulse amplitude. The sensitivity and specificity of the pulse amplitude measured with the LDF for detecting PAD in HD patients as determined by a receiver operating characteristic curve analysis were 1.00 and 0.88, respectively. Conclusion: Measuring the pulse amplitude in the toe with a portable LDF may serve as a simple and useful screening test for PAD in HD patients.

Outcomes of Intermittent Infusion Hemodiafiltration in Patients with Cardiac Hypofunction on Maintenance Hemodialysis.

BACKGROUND: Following the onset of heart failure symptoms, fluid removal is usually intensified, but patients with decreased cardiac function may develop sudden hypotension due to poor plasma refilling and functional impairment of the mechanisms that maintain blood pressure. In these patients, removal of fluids then becomes difficult. Impairment of the mechanisms that maintain blood pressure can be treated with vasopressors, but intermittent infusion hemodiafiltration (I-HDF) may be effective for managing poor plasma refilling. Thus, here I-HDF was performed in patients with cardiac hypofunction who were undergoing maintenance hemodialysis (HD) in order to assess the clinical effects. SUMMARY: Participants were 5 patients with cardiac hypofunction on maintenance HD. HD and I-HDF were performed for a total of 6 months each. A comparison was made of changes in dry weight (DW) and cardiothoracic ratio (CTR), blood test results, echocardiography findings, plasma -refilling rate (PRR), and tissue blood flow. During I-HDF, a decrease in DW was achieved and CTR was significantly improved. Echocardiographic findings showed that left ventricular diameter improved significantly during I-HDF. Higher PRR values and increased tissue blood flow were -observed during I-HDF compared with HD. Intermittent infusions during I-HDF prevented organ ischemia and suppressed the De Jager-Krogh phenomenon. This may be associated with the promotion of stable plasma refilling. Key Messages: Excessive fluid retention is a cause of heart failure symptoms. I-HDF facilitates removal of excessive fluid and thereby possibly contributes to the improvement of cardiac function.

Development of a Caco-2 Cell Line Carrying the Human Intestine-Type CES Expression Profile as a Promising Tool for Ester-Containing Drug Permeability Studies.

Carboxylesterase 2 (CES2), which is a member of the serine hydrolase superfamily, is primarily expressed in the human small intestine, where it plays an important role in the metabolism of ester-containing drugs. Therefore, to facilitate continued progress in ester-containing drug development, it is crucial to evaluate how CES2-mediated hydrolysis influences its intestinal permeability characteristics. Human colon carcinoma Caco-2 cells have long been widely used in drug permeability studies as an enterocyte model. However, they are not suitable for ester-containing drug permeability studies due to the fact that Caco-2 cells express CES1 (which is not expressed in human enterocytes) but do not express CES2. To resolve this problem, we created a new Caco-2 cell line carrying the human small intestine-type CES expression profile. We began by introducing short-hairpin RNA for CES1 mRNA knockdown into Caco-2 cells to generate CES1-decifient Caco-2 cells (Caco-2CES1KD cells). Then, we developed Caco-2CES1KD cells that stably express CES2 (CES2/Caco-2CES1KD cells) and their control Mock/Caco-2CES1KD cells. The results of a series of functional expression experiments confirmed that CES2-specific activity, along with CES2 mRNA and protein expression, were clearly detected in our CES2/Caco-2CES1KD cells. Furthermore, we also confirmed that CES2/Caco-2CES1KD cells retained their tight junction formation property as well as their drug efflux transporter functions. Collectively, based on our results clearly showing that CES2/Caco-2CES1KD cells carry the human intestinal-type CES expression profile, while concomitantly retaining their barrier properties, it can be expected that this cell line will provide a promising in vitro model for ester-containing drug permeability studies.

Clinical significance of an inflammation-based prognostic system for gastric cancer patients with a preoperative normal serum level of carcinoembryonic antigen.

AIM: To investigate the significance of the Glasgow Prognostic Score (GPS) for predicting the postoperative survival of gastric cancer (GC) patients with a normal preoperative serum level of carcinoembryonic antigen (CEA). Because CEA is a useful marker for prognostication of several types of cancer, some patients with GC have a normal CEA level. On the other hand, the GPS has been established as a valuable inflammation-based prognostic system for cancer patients. PATIENTS AND METHODS: Among 650 patients who had undergone elective surgery for GC, 425 with a normal preoperative serum CEA level (≤5.0 ng/ml) were enrolled. Uni- and multivariate analyses were performed to evaluate the relationship of the GPS to overall survival. The Kaplan-Meier analysis and log rank test were used to compare the survival curves among patients with GPS 0, 1 and 2. RESULTS: Multivariate analysis using clinical characteristics selected from univariate analyses revealed that the GPS (0, 1/2) was associated with overall survival (hazard ratio=2.048; 95% C.I. (confidence interval)=1.002-4.185; p=0.049) along with age (≤70/>70) (years), sex, tumor type (3, 4, 5/0, 1, 2), lymph node metastasis (presence/absence) and platelet count (≤35/>35) (×10(4)/mm(3)). The Kaplan-Meier analysis and log rank test demonstrated that there were significant differences in overall survival among patients with GPS 0, 1 and 2 (p<0.001). CONCLUSION: Even if GC patients have a normal serum level of CEA, the GPS is able to predict their postoperative survival and classify such patients into three independent groups before surgery.

Combination of platelet count and neutrophil to lymphocyte ratio is a useful predictor of postoperative survival in patients undergoing surgery for gastric cancer.

OBJECTIVE: To investigate the clinical utility of the Combination of Platelet count and Neutrophil to Lymphocyte Ratio (COP-NLR) for predicting the postoperative survival of patients undergoing surgery for gastric cancer (GC). METHODS: The COP-NLR was calculated on the basis of data obtained on the day of admission as follows: patients with both an elevated platelet count (>300 × 10(3) /µl) and an elevated NLR (>3) were allocated a score of 2, and patients showing one or neither were allocated a score of 1 or 0, respectively. Five hundred forty-four patients for whom data were sufficient to allow analysis of the relationship between clinicolaboratory characteristics and postoperative survival were enrolled. RESULTS: Multivariate analysis using the 12 clinical characteristics selected by univariate analyses revealed that the COP-NLR was associated with OS (hazard ratio, 1.781; 95% C.I., 1.094-2.899; P = 0.020) along with age, tumor type, lymph node metastasis and albumin level. Kaplan-Meier analysis and log rank test demonstrated significant differences in both OS and cancer-specific survival among patients with COP-NLR 0, 1, and 2 (P < 0.001). CONCLUSION: The COP-NLR is able to predict postoperative survival of patients with GC and classify such patients into three independent groups before surgery.

Prognostic nutritional index is associated with survival after total gastrectomy for patients with gastric cancer.

AIM: To investigate the influence of clinical characteristics including nutritional markers on postoperative survival in patients undergoing total gastrectomy (TG) for gastric cancer (GC). PATIENTS AND METHODS: One hundred fifty-four patients were enrolled. Uni- and multivariate analyses using the Cox proportional hazard model were performed to explore the most valuable clinical characteristic that was associated with postoperative survival. RESULTS: Multivariate analysis using twelve clinical characteristics selected from univariate analyses revealed that age (≤ 72/>72), carcinoembryonic antigen (≤ 20/>20) (ng/ml), white blood cell count (≤ 9.5/>9.5) (× 10(3)/mm(3)), prognostic nutritional index (PNI) (≤ 45/>45) and lymph node metastasis (negative/positive) were associated with postoperative survival. Kaplan-Meier analysis and log-rank test showed that patients with higher PNI (>45) had a higher postoperative survival rate than those with lower PNI (≤ 45) (p<0.001). CONCLUSION: PNI is associated with postoperative survival of patients undergoing TG for GC and is able to divide such patients into two independent groups before surgery.

Primary and secondary adenocarcinomas associated with anal fistulae.

PURPOSE: The purpose of this study was to evaluate the clinical features, pathology, and etiology of adenocarcinoma in patients with anal fistulae. METHODS: We identified seven patients diagnosed with adenocarcinoma associated with anal fistulae from a retrospective chart review. RESULTS: Five patients were diagnosed with primary adenocarcinoma associated with anal fistulae. Two patients were diagnosed with secondary adenocarcinoma associated with anal fistulae originating from rectal cancer on the proximal side. The primary adenocarcinomas included cancers arising from long-standing anal fistulae fulfilling established diagnostic criteria in two patients, and cancer arising from short-duration anal fistulae in three patients. Excision of the fistula was performed based on the initial diagnosis of the anal fistula for all five patients. Increased suspicion of cancer was due to the existence of gelatinous material in the anal fistula in three patients and induration in the resected specimens in two patients. The etiologies of the secondary adenocarcinomas associated with anal fistulae included implantation in the anal fistula from rectal cancer and fistula formation originating due to the progression of rectal cancer. CONCLUSION: Anal fistulae are commonly seen in the coloproctology clinic, but special attention to similar conditions associated with malignant disease is needed.