Investigation of the key determinants of Asian nurses' quality of life.

The study aimed to compare nurses' quality of life and investigate key determinants among Asian countries with different economic status. A cross-sectional survey was conducted across five Asian countries (Japan, Singapore, Malaysia, Thailand, and Bhutan). Quality of life (WHOQOL-BREF), job stress (National Institute of Occupational Safety and Health questionnaire), and demographic data were assessed. Stepwise multivariate linear regression analysis was performed to identify the key determinants of quality of life. Participants were 3,829 nurses (response rate: 82%) with a mean age of 33 ± 10 yr and majority were women (92%). Regarding quality of life, Bhutan yielded the highest scores, followed by Malaysia, Thailand, Singapore, and Japan, and these results were statistically significant. The key determinants that were significantly related to quality of life were "stress coping ability," "life satisfaction," "Japan," "social support," "job stress," and "Singapore" (adjusted R2=0.46). In conclusion, nurses' quality of life differs across Asian countries and is not linked to the country's economic development. To maintain a good quality of life for nurses, an international exchange program like international nursing conferences for work environment and staff coping strategies is recommended to broaden institution' minds and share experiences and exchange views to be able to realize their own problems and discover global solutions to them.

Impact of work-life imbalance on job satisfaction and quality of life among hospital nurses in Japan.

This study investigated the status of work-life imbalance among hospital nurses in Japan and impact of work-life imbalance on job satisfaction and quality of life. A cross-sectional survey of 1,202 nurses (81% response rate) was conducted in three Japanese acute care hospitals. Participants were divided into four groups for actual work-life balance (Group A: 50/50, including other lower working proportion groups [e.g., 40/50]; Group B: 60/40; Group C: 70/30; and Group D: 80/20, including other higher working proportion groups [e.g., 90/10]). We also asked participants about desired work-life balance, and private and work-related perspectives. Satisfactions (job, private life, and work-life balance), quality of life, and stress-coping ability were also measured. All data were compared among the four groups. Most nurses sensed that they had a greater proportion of working life than private life, and had a work-life imbalance. Actual WLB did not fit compared to desired WLB. When the actual working proportion greatly exceeds the private life proportion, nurses' health could be in danger, and they may resign due to lower job satisfaction and QOL. Simultaneous progress by both management and individual nurses is necessary to improve work-life imbalance.

Pigmentary complication of the peristomal skin in colorectal cancer patients under systemic chemotherapy using S-1: report of cases.

PURPOSE: This study describes hyperpigmentation at the epidermis around a colostomy during and after systemic chemotherapy with S-1 (a compound of tegaful, gimestat, and potassium oxonate). SUBJECTS AND SETTING: Thirty-one colorectal cancer patients (male 17, female 14) visited the stoma-care clinic, akita university hospital between april 2003 and march 2006. fourteen patients (male 8, female 6) had been observed continuously for more than 3 months. METHODS: Results of 5 male patients who received systemic chemotherapy using S-1 were compared to those of 9 male and female patients who did not receive S-1. the shades of epidermal pigmentation at the peristomal area were graded on a 3-point likert scale, where grade 2 indicated very dark pigmentation, grade 1 indicated moderately dark pigmentation, and grade 0 indicated no pigmentation of the peristomal skin. RESULTS: Pigmentation scores in patients receiving S-1 were significantly higher than scores in patients who did not receive S-1 systemic chemotherapy. CONCLUSIONS: Rapid and excessive pigmentation of the peristomal skin may occur in patients receiving S-1 systemic chemotherapy because it indicates an adverse event related with systemic chemotherapy and leads to peristomal skin problems.

A case report of pediatric fulminant hepatitis treated with plasma diafiltration.

Plasma diafiltration (PDF) is blood purification therapy in which simple plasma exchange is performed with a membrane plasma separator while dialysate flows outside the hollow fibers. A 14-year-old boy with fulminant hepatitis underwent two sessions of PDF and one session of hemodiafiltration. We infused filtered replacement fluid for artificial kidneys at a dialysate flow rate of 600 mL/h and a replacement flow rate of 450 mL/h. We infused fresh frozen plasma (1200 mL) and 25% albumin solution (50 mL) intravenously over 8 h. Each PDF session lasted 8 h. The patient's total bilirubin, interleukin-18, and cystatin C levels decreased with treatment, and he recovered from hepatic failure. PDF may be an extremely useful blood purification therapy for pediatric fulminant hepatitis in terms of both medical economics and cytokine removal.

Study of safe usage of high-flow three-way stopcocks in a blood circuit.

To examine the safety of using a high-flow three-way stopcock in a blood circuit during extracorporeal blood purification therapy, we studied the risk of development of hemolysis and clot formation in both ex vivo and in vivo extracorporeal circulation. In the ex vivo study, no significant difference was observed in the decrease in hematocrit (HCT) or increase in the potassium level between the three-way stopcock group and the control group. Nor was there a significant difference in the change in inlet pressure between the two groups. Thus, it was shown that the risk of hemolysis caused by the use of a high-flow three-way stopcock on both the outlet side and inlet side would be small. In the in vivo cases, there was no significant difference in the decrease in HCT or the increase in inlet pressure between the three-way stopcock group and control group, suggesting that it is clinically possible to incorporate a high-flow three-way stopcock into a blood circuit.

Combining continuous endotoxin apheresis and continuous hemodiafiltration in the treatment of patients with septic multiple organ dysfunction syndrome.

When septic multiple organ dysfunction syndrome (MODS) occurs as a result of endotoxemia, diverse chemical mediators are excessively produced, and the patient becomes seriously ill. Under such circumstances, it is difficult to improve the patient's condition by endotoxin apheresis alone and hemodiafiltration should be carried out to remove excessive chemical mediators. Series-parallel treatment combining continuous endotoxin apheresis and hemodiafiltration is recommended for patients with septic MODS.

Effectiveness of combining plasma exchange and continuous hemodiafiltration in patients with postoperative liver failure.

Nine patients with postoperative liver failure were treated with plasma exchange (PE) or PE and continuous hemodiafiltration (CHDF), and various biochemical parameters were determined before and after treatment. Although citrate levels increased significantly after treatment compared with pretreatment levels in both the PE group and the PE + CHDF group (P < 0.0001 and P < 0.0001, respectively), the percentage of the increase in citrate levels was significantly higher in the PE group than in the PE + CHDF group (P = 0.0051). Total bilirubin (T-Bil) levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0001, respectively). There were no significant differences in T-Bil levels between the two groups (P = 0.5181). There were no significant differences in interleukin (IL)-6 levels before and after treatment in both the PE and PE + CHDF groups (P = 0.1281 and P = 0.2273, respectively). IL-18 levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0002, respectively), but there were no significant differences in the removal rate of IL-18 in both the PE and PE + CHDF groups (P = 0.8749). These results indicate that combining PE and CHDF in a series-parallel circuit is an effective modality for suppressing the elevation of blood citrate levels. This finding may have important implications for the development of an effective treatment for patients with postoperative liver failure.

Treatment of multiple organ failure through sepsis by surgery and blood purification.

For the treatment of multiple organ failure (MOF) through sepsis, we have commonly applied various blood purification modalities during the perioperative period. From January 1996 to December 2000, 33 patients with MOF through sepsis were admitted and operated on in the First Department of Surgery, Akita University School of Medicine, and 21 of these 33 patients were treated using various blood purification modalities during the perioperative period: endotoxin-adsorbing therapy using polymyxin B (PMX) in 17 patients, continuous hemofiltration (CHF)/continuous hemodiafiltration (CHDF) in 15 patients, and plasma exchange (PE) and CHDF in 3 patients. Of the outcome of these 33 patients with MOF through sepsis, 17 survived and 16 died (48% mortality). Of the 21 patients with MOF through sepsis treated by surgery and blood purification, 12 survived and 9 died (43% mortality). We evaluated APACHE II and the number of failed organs before operation. Amongst the group with 12 survivors and 9 deaths, Acute Physiology and Chronic Health Evaluation II (APACHE II) was 15 +/- 5, 23 +/- 2 and the number of failed organs was 2.7 +/- 0.7, 3.9 +/- 0.8, respectively. An increased APACHE II score and number of failed organs were significantly associated with mortality. As to the treatment of MOF through sepsis due to acute peritonitis, patients with APACHE II scores ranging from 15 to 20, and those with 2-3 failed organs seem to be the candidates for the application of blood purification during the perioperative period.

Role of positron emission tomography with 2-deoxy-2-[18F]fluoro-D-glucose in evaluating the effects of arterial infusion chemotherapy and radiotherapy on pancreatic cancer.

BACKGROUND: This study evaluated the usefulness of positron emission tomography with 2-deoxy-2-[18F]fluoro-D-glucose (FDG-PET) in monitoring the response to continuous arterial infusion chemotherapy (CAI) combined with external radiation therapy (ERT) for unresectable pancreatic carcinomas. METHODS: Ten patients with unresectable pancreatic cancer were enrolled in this study. Computed tomography (CT) and FDG-PET were done before and after CAI (5-fluorouracil [FU], 500 mg/body per day) combined with ERT (50.4 Gy total dose). Tumor regression was evaluated by standardized uptake value (SUV) with FDG-PET, tumor size on CT, and changes in blood levels of carbohydrate antigen (CA) 19-9. The three methods of evaluation were compared. RESULTS: The ten patients were classified in three categories. In category I, tumor changes evident on CT and FDG-PET were consistent. In category II, CT could not accurately detect the area of the tumor. However, tumor uptake on FDG-PET decreased markedly after the treatment in category II patients. In category III, both CT and FDG-PET detected the tumor, as in category I. Although there was no definite change in tumor size on CT, FDG-PET uptake was markedly reduced immediately after the treatment. Reduction in tumor size did not appear on CT until 2 months later. CONCLUSIONS: FDG-PET aids in analysis of the effectiveness of chemotherapy and/or radiotherapy.

Outcomes and indications of segmental pancreatectomy. Comparison with distal pancreatectomy.

BACKGROUND/AIM: To preserve pancreatic function, segmental pancreatectomy has been proposed for benign or low-malignancy tumors in the pancreatic body. Indications for the procedure, however, are still controversial. METHODS: In this study, we investigated the advantages and disadvantages of segmental pancreatectomy compared with distal pancreatectomy and subsequently determined indications for segmental pancreatectomy. RESULTS: The distal pancreatectomy patients had shorter operation times, lower incidence of operative complications, and shorter hospital stays compared to segmental pancreatectomy patients. Endocrine function in distal pancreatectomy patients deteriorated compared to that of segmental pancreatectomy patients. The postoperative 75-gram oral glucose tolerance test showed a diabetic pattern in 3 of 7 distal pancreatectomy patients, whereas none of the segmental pancreatectomy patients became diabetic after surgery. The relation between the length of the removed pancreas and plasma glucose at 2 h after the 75-gram glucose intake showed a significant correlation. CONCLUSION: According to our results, if the length of removed pancreas is longer than 12 cm, the patients will have a risk of acquiring diabetes. In those cases, the segmental pancreatectomy should be considered.

Treatment for postoperative liver failure after major hepatectomy under hepatic total vascular exclusion.

Hepatic total vascular exclusion (HTVE) with clamping of the portal triad and the inferior vena cava below and above the liver is a useful technique in the resection of major hepatic lesions situated close to the hepatic veins and inferior vena cava. From 1996 to 2000, five patients underwent major hepatectomy under HTVE; among these, liver failure occurred in two patients because of liver cirrhosis or hepatic artery interruption. In the former case, apheresis therapy (plasma exchange: 9 times), continuous prostaglandin E, (PGE,) infusion via the hepatic artery(0.01 tg/kg/min) for 7 days, and hyperbaric oxygen therapy (3 times: 2 ATA, 60 min) were applied. In the latter case, apheresis therapy (plasma exchange: 9 times, continuous hemodiafiltration: 12 days) and continuous PGE, infusion via the superior mesenteric artery for 7 days were applied. With these treatment modalities, both cases were cured of postoperative liver failure.

Efficacy of continuous infusion of prostaglandin E1 through the superior mesenteric artery against ischemic liver cell necrosis after hepatic artery occlusion.

BACKGROUND: Hepatic artery occlusion (HAO) can cause severe ischemic liver injury, especially after an interruption of collateral circulation after extensive hepatobiliary surgery. To minimize a decrease in oxygen delivery after HAO, a continuous infusion of prostaglandin (PG)E1 through the superior mesenteric artery (SMA) was studied in comparison with other infusion routes. METHODS: Twenty-four pigs were assigned to four groups: HAO without PGE1 (control group); HAO with PGE1 (0.02 microg/kg/min, continuously) through the jugular vein (intravenous group); HAO with PGE1 through the portal vein (PV group); and HAO with PGE1 through the SMA (SMA group). PV flow, hepatic oxygen delivery, and serum aspartate aminotransferase were measured after infusion. In addition, 72-hr survival rates were observed, and histologic examination of liver specimens was performed. RESULTS: PGE1 infusion through the SMA seems to affect PV flow and elevate the oxygen content of portal blood, whereas other routes of administration do not. The reduction of hepatic oxygen delivery after HAO was 51% in the control group, 46% in the intravenous group, and 49% in the PV group, whereas it was limited to 13% in the SMA group. Serum aspartate aminotransferase values 24 hr after HAO were lowest in the SMA group, which was statistically significant, as confirmed by histology. The survival rate of animals was 100% in the SMA group and 33% in the other three groups. CONCLUSION: These findings indicate that continuous PGE1 infusion through the SMA may prove useful in clinical settings to prevent liver damage after HAO.

Two cases of hepatic artery interruption after hepatopancreatobiliary surgery treated by prostaglandin E(1) infusion via the superior mesenteric artery.

In two cases of hepatic arterial flow interruption after hepatopancreatic surgery, continuous PGE(1) infusion from the superior mesenteric artery (SMA) was applied to oxygenate the liver through the portal vein. Case 1 was a 69-year-old woman with a non-functioning islet cell tumor of the pancreas. She underwent pancreatic resection following hepatic arterial infusion of anticancer drugs. Serum alanine aminotransferase (ALT) was elevated to 5500 IU/l on postoperative day (POD) 2; angiography revealed complete celiac artery obstruction. Continuous PGE(1) was administered from SMA at a rate of 0.01 &mgr;g/kg/min for 7 days. Serum ALT was normalized within 2 weeks and the peak level of serum total bilirubin (T. Bil) was 4.5 mg/dl. Case 2 was a 66-year-old man suffering from metastatic liver cancer. Complete obstruction of the proper hepatic artery was noted at the time of liver resection after hepatic arterial chemotherapy. Serum ALT was elevated to 2930 IU/l on POD 1, and PGE(1) infusion from SMA was done for the succeeding 7 days. Necrotic area was so vast that serum T. Bil rose to 19 mg/dl. However, it decreased with time. Both cases required 3 months for necrotic liver shrinkage. Doppler ultrasonography revealed that PGE(1) infusion actually increased portal blood flow. In conclusion, based on the preceding experimental backgrounds and clinical experiences, continuous PGE(1) infusion via the SMA can be a useful measure to prevent severe liver damage after hepatic arterial flow interruption through portal blood oxygenation.

Jejunal varix with extrahepatic portal obstruction treated by embolization using interventional radiology: report of a case.

We report a case of relapsing jejunal varix with extrahepatic portal obstruction, which was successfully treated by embolization using interventional radiology. A 79-year-old woman suffered repeated episodes of tarry stools 2 years after undergoing jejunal resection for a jejunal varix. The bleeding point was inferred to be in the small intestine, and abdominal angiography revealed extrahepatic portal obstruction and the development of a jejunal varix around the hepaticojejunostomy. Because surgical obliteration of the varices or a shunt operation for portal decompression may have been very invasive due to severe adhesions, the jejunal varix was embolized with anhydrous ethanol and interlocking detachable coils. There were no changes in liver enzymes, the clearance rate of indocyanine green, or portal pressure, and there has been no sign of rebleeding for 13 months. Our experience shows that hemostasis can last, as long as the embolization can be done without aggravating portal hypertension. In conclusion, embolization using interventional radiology is a safe and useful method of treating intestinal varices.

Positron emission tomography with 2-deoxy-2-[(18)F] fluoro- d-glucose for diagnosis of intraductal papillary mucinous tumor of the pancreas with parenchymal invasion.

We used positron emission tomography with 2-deoxy-2-[(18)F]fluoro- d-glucose (FDG-PET) in the diagnosis of two cases of malignant intraductal papillary mucinous tumor (IPMT) of the pancreas. A 56-year-old man and a 72-year-old man, both with tumors in the pancreatic head, were referred to Akita University Medical Center. Computed tomography revealed tumors with multiple cystic components in both patients. FDG-PET images showed markedly high FDG uptake in the area corresponding to a solid component found in one patient and diffuse faint uptake, higher than that of the surrounding tissue, in the other patient, who had no solid component. Histological examination of the resected specimens after pancreatectomy showed invasive carcinoma involving the pancreatic parenchyma in both patients. Although our experience is limited and preliminary, FDG-PET seems to be useful for the detection of malignancy in IPMT, especially in patients not showing any solid component on conventional diagnostic images such as computed tomography.

Cytokine removal by plasma exchange with continuous hemodiafiltration in critically ill patients.

The effectiveness of plasma exchange (PE) with continuous hemodiafiltration (CHDF) in the treatment of critically ill patients was evaluated based on changes in cytokine levels. Twenty-six patients with acute hepatic failure were treated with PE (PE group) or PE and CHDF (PE+CHDF group), and the levels of cytokines such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, and IL-8 were determined before and after treatment. Bilirubin levels were significantly lower after treatment in both the PE and PE+CHDF groups. There were no significant differences in TNF-alpha levels before and after treatment in the PE group, but the TNF-alpha level was significantly lower after treatment in the PE+CHDF group. There were no significant differences in the IL-6 levels before and after treatment in both the PE and PE+CHDF groups. There were no significant differences in IL-8 levels before and after treatment in the PE group, but the IL-8 level was significantly lower after treatment in the PE+CHDF group. PE with CHDF therapy was given to 5 patients with acutely aggravated autoimmune diseases, 2 patients with hemorrhagic shock and encephalopathy syndrome, and 3 patients with thrombotic microangiopathy. The results suggested that PE with CHDF therapy are useful in critically ill patients with suspected hypercytokinemia.

Management of pancreatic mass accompanying chronic pancreatitis.

We report two patients with focal, chronic pancreatitis that was diagnosed by dynamic computed tomography (CT) combined with intraoperative biopsy. In case 1, serum carbohydrate antigen (CA) 19-9 level rose to 160 U/ml. Abdominal ultrasonography, CT, and magnetic resonance imaging demonstrated a mass, of 4.5 cm in diameter, in the pancreatic head. On dynamic CT, the mass was enhanced similarly to the normal pancreatic parenchyma. In case 2, dynamic CT demonstrated a mass, of 3.0 cm in diameter, in the pancreatic head, which was enhanced similarly to the normal pancreatic parenchyma. From such characteristics of enhancement, both masses were suspected to be chronic pancreatitis rather than cancer, and the diagnosis was confirmed by intraoperative biopsy. Three years in case 1 and 2 years in case 2 have passed since their operations, and the size of each mass has not changed. With the use of dynamic CT combined with intraoperative biopsy, focal chronic pancreatitis could be diagnosed more accurately, and this may lead to a reduction in unnecessary pancreatic resection.

Uptake of indocyanine green by hepatocytes under inflow occlusion of the liver.

BACKGROUND: It is not clear that hepatic venous backflow actually contributes to hepatic tissue oxygenation under inflow occlusion of the liver. In order to prove that substances delivered via the hepatic vein can be utilized and/or metabolized in hepatocytes during inflow occlusion, hepatic uptake in bile and excretion of indocyanine green (ICG) were investigated in pigs. MATERIALS AND METHODS: Animals were divided into two groups: an inflow occlusion (IO) group (N = 6) and a total hepatic vascular exclusion (THVE) group (N = 3) using a bypass. One milligram of ICG per kilogram body weight was administered at the beginning of blood flow occlusion, the retention rate in the blood (ICG R) measured, and the ICG in the hepatic tissue measured by near-infrared (NIR) spectroscopy. Furthermore, the ICG concentration was measured in bile excreted by intermittent perfusion of the liver. RESULTS: ICG R declined with time in both groups; however, ICG R in the IO group decreased much faster than in the THVE group. There were significant differences between the two groups after 30 min of occlusion (P < 0.05). ICG in the hepatic tissue could be detected as a peak at 805 nm 10 min after ICG injection, and the peak became steeper with time. On the other hand, ICG was not detected at all in the hepatic tissue after 180 min in the THVE group. ICG was excreted in the bile after 60 min under IO and increased with time. On the contrary, ICG was not excreted in the bile at all under THVE. There were significant differences between the two groups after 90 min (P < 0.05). CONCLUSION: These results indicate that ICG can be extracted in hepatocytes and excreted in bile under IO of the liver. Consequently, substances such as oxygen and drugs, which are delivered via the hepatic vein, can be utilized and/or metabolized in hepatocytes under IO.

Regional and general effects of hepatic lobes with impaired blood flow after hepatic resection.

BACKGROUND/AIMS: In hepatic surgery, blood flow to some parts of the liver may become impaired. At present, no consensus has been reached on ways to treat such affected parts of the liver with impaired blood supply. METHODOLOGY: After the ligation of branches of rat's hepatic artery and/or portal vein, the ligated and non-ligated lobes were studied at fixed intervals up to 84 days. Parameters include hepatic tissue blood flow assessed by a laser Doppler flowmeter, liver regeneration ability using bromodeoxyuridine, apoptosis using anti-single-stranded DNA Ig-G antibody, and vulnerability to an endotoxic injection. RESULTS: Hepatic artery ligation group showed no obvious changes in either the ligated or non-ligated lobes, and these lobes had no effects on the whole body. Of the portal vein ligation group, although the ligated lobes underwent marked atrophy, the compensatory hypertrophy of the non-ligated lobes took place sufficiently and no life-threatening conditions were observed. With regard to the hepatic artery/portal vein ligation (HA/PVL) group, hepatic blood flow in the ligated lobes rapidly decreased, and all hepatocytes underwent necrosis 1 day after surgery. In the non-ligated lobes, however, significant increases in the bromodeoxyuridine labeling index were detected at 1, 2, and 3 days after surgery, and compensatory hypertrophy was recognized. Indocyanine green 15-minute retention rate rapidly increased 1 day after surgery, and there were significant differences compared to the sham group up to 7 days after surgery. The postsurgical mortality rate in the HA/PVL group was significantly high at 13%, and mortality rate following endotoxin injection was as high as 75%. CONCLUSIONS: Affected parts of the liver with blockage of both the hepatic artery and portal vein should be resected.

Continuous arterial infusion of prostaglandin E(1) via the superior mesenteric artery in the treatment of postoperative liver failure.

Impaired hepatic blood flow is one of the causative factors in postoperative liver failure. To restore the hepatic blood flow in case of hepatic artery interruption (HAI), the effect of continuous arterial infusion of prostaglandin E(1) (PGE(1)), which has a strong vasodilatory effect on vascular smooth muscles, was assessed experimentally and clinically. Twelve pigs underwent ligation and division of the hepatic artery and were divided into 2 groups. In the control group, saline was infused in the superior mesenteric artery (SMA), and in the PGE(1) group, 0.02 microg/kg/min of PGE(1) was infused continuously in the SMA. Hepatic oxygen delivery (HDO(2)) in the control group was 87.8 +/- 8.9 ml/min before HAI and decreased to 43.1 +/- 2.6 ml/min at 60 min after HAI, showing 50.9% decrease by HAI. On the contrary, HDO(2) in the PGE(1) group was 86.7 +/- 9.1 ml/min before HAI and was 76.6 +/- 12.2 ml/min at 60 min after HAI, showing only 11.6% decrease by HAI. Clinically, a 65-year-old female suffering from cholangiocellular carcinoma underwent extended left hepatic lobectomy. At operation, the branch of the hepatic artery to the anterior segment of the liver was ligated, and the right branch of the portal vein became stenotic unavoidably. Postoperatively, severe liver dysfunction developed so that continuous PGE1 infusion in the SMA was initiated at a rate of 0.01 microg/kg/min on the eighth postoperative day and continued for 9 days. Plasma exchange was performed twice concomitantly. Portal venous flow increased from 612 ml/min to 1,192 ml/min, and bile flow from external biliary drainage tube doubled by the PGE(1) infusion. The liver function was ameliorated after PGE(1) infusion.