Development of Nursing Protocol for Preventing Interruptions during Clinical Examinations and Treatments in the Early Days of Hospitalization for Acute Exacerbation of Chronic Heart Failure in Patients with Impaired Cognitive Function

The purpose of this study is to prepare a nursing protocol for preventing interruptions during clinical examinations and treatments performed in the early days of hospitalization for acute exacerbation of chronic heart failure in patients with impaired cognitive function. For the first stage of the research, we prepared a draft of the nursing protocol based on a basic survey. For the second stage, semi-structured interviews were conducted with 5 nurses specialized in chronic heart failure and 11 nurses in dementia care to ensure content validity of the draft protocol. For the third stage, we examined the possibility of clinical application of the revised version of the protocol draft prepared in the second stage of the study. For assessment items, significant points of nursing care, and specific nursing care practice in this revised version, 73 subjects (84.9%) considered effective for patients, in terms of prevention of interruptions during clinical examinations and treatments in the early days of hospitalization. All items and contents were considered useful by more than 60% of the nurses. Considering that the nurses working in the clinical setting reported 84.9% of usefulness, we concluded that this nursing protocol remained valid at a certain level. We consider that this nursing protocol will be useful especially for newly graduated/employed nurses as a procedure manual which can reduce their anxiety or stress caused by lack of knowledge or experiences.

Current state of practice for colonic diverticular bleeding in 37 hospitals in Japan:A multicenter questionnaire study

AIMTo clarify the current state of practice for colonic diverticular bleeding(CDB)in Japan.METHODSWe conducted multicenter questionnaire surveys of the practice for CDB including clinical settings(8 questions),diagnoses(8 questions),treatments(7 questions),and outcomes(4 questions)in 37 hospitals across Japan.The answers were compared between hospitals with high and low number of inpatient beds to investigate which factor influenced the answers.RESULTSEndoscopists at all 37 hospitals answered the questions,and the mean number of endoscopists at these hospitals was 12.7.Of all the hospitals,computed tomography was performed before colonoscopy in 67%of the hospitals.The rate of bowel preparation was 46.0%.Early colonoscopy was performed within 24 h in 43.2%of the hospitals.Of the hospitals,83.8%performed clipping as first-line endoscopic therapy.More than half of the hospitals experienced less than 20%rebleeding events after endoscopic hemostasis.No significant difference was observed in the annual number of patients hospitalized for CDB between high-(≥700 beds)and low-volume hospitals.More emergency visits(P=0.012)and endoscopists(P=0.015),and less frequent participation of nursing staff in early colonoscopy(P=0.045)were observed in the high-volume hospitals.CONCLUSIONSome practices unique to Japan were found,such as performing computed tomography before colonoscopy,no bowel preparation,and clipping as first-line therapy.Although,the number of staff differed,the practices for CDB were common irrespective of hospital size.

Recent evidence for subcutaneous drains to prevent surgical site infections after abdominal surgery:A systematic review and metaanalysis

BACKGROUND Surgical site infections(SSIs)increase mortality,hospital stays,additional medical treatment,and medical costs.Subcutaneous drains prevent SSIs in gynecological and breast surgeries;however,their clinical impact in abdominal surgery remains unclear.AIM To investigate whether subcutaneous drains were beneficial in abdominal surgery using a systematic review and meta-analysis.METHODS The database search used PubMed,MEDLINE,and the Cochrane Library.The following inclusion criteria were set for the systematic review:(1)Randomized controlled trial studies comparing SSIs after abdominal surgery with or without subcutaneous drains;and(2)Studies that described clinical outcomes,such as SSIs,seroma formation,the length of hospital stays,and mortality.RESULTS Eight studies were included in this meta-analysis.The rate of total SSIs was significantly lower in the drained group(54/771,7.0%)than in the control group(89/759,11.7%),particularly in gastrointestinal surgery.Furthermore,the rate of superficial SSIs was slightly lower in the drained group(31/517,6.0%)than in the control group(49/521,9.4%).No significant differences were observed in seroma formation between the groups.Hospital stays were shorter in the drained group than in the control group.CONCLUSION Subcutaneous drains after abdominal surgery prevented SSIs and reduced hospital stays but did not significantly affect seroma formation.The timing of drain removal needs to be reconsidered in future studies.

Colorectal endoscopic submucosal dissection: Recent technical advances for safe and successful procedures

Endoscopic submucosal dissection(ESD) is very useful in en bloc resection of large superficial colorectal tumors but is a technically difficult procedure because the colonic wall is thin and endoscopic maneuverability is poor because of colonic flexure and extensibility. A high risk of perforation has been reported in colorectal ESD. To prevent complications such as perforation and unexpected bleeding, it is crucial to ensure good visualization of the submucosal layer by creating a mucosal flap, which is an exfoliated mucosa for inserting the tip of the endoscope under it. The creation of a mucosal flap is often technically difficult; however, various types of equipment, appropriate strategy, and novel procedures including our clip-flap method, appear to facilitate mucosal flap creation, improving the safety and success rate of ESD. Favorable treatment outcomes with colorectal ESD have already been reported in many advanced institutions, and appropriate understanding of techniques and development of training systems are required for world-wide standardization of colorectal ESD. Here, we describe recent technical advances for safe and successful colorectal ESD.

Impact of time from diagnosis to chemotherapy in advanced gastric cancer: A Propensity Score Matching Study to Balance Prognostic Factors

BACKGROUND It is unclear whether treatment delay affects the clinical outcomes of chemotherapy in advanced gastric cancer(A-GC).AIM To assess whether treatment delay affects the clinical outcomes of chemotherapy in A-GC.METHODS This single-center retrospective study examined consecutive patients with A-GC between April 2012 and July 2018. In total, 110 patients with stage Ⅳ A-GC who underwent chemotherapy were enrolled. We defined the wait time(WT) as the interval between diagnosis and chemotherapy initiation. We evaluated the influence of WT on overall survival(OS).RESULTS The mean OS was 303 d. The median WT was 17 d. We divided the patients into early and elective WT groups, with a 2-wk cutoff point. There were 46 and 64 patients in the early and elective WT groups, respectively. Compared with the elective WT group, the early WT group had significantly lower albumin(Alb)levels and higher neutrophil/lymphocyte ratios and C-reactive protein(CRP)levels but not a lower performance status. The elective WT group underwent more combination chemotherapy than did the early WT group. OS was different between the two groups(230 d vs 340 d, respectively). Multivariate analysis revealed that higher CRP levels, lower Alb levels and monotherapy were significantly related to a poor prognosis. To minimize potential selection bias,patients in the elective WT group were 1:1 propensity score matched with patients in the early WT group; no significant difference in OS was found(303 d vs 311 d, respectively, log-rank P = 0.9832).CONCLUSION A longer WT in patients with A-GC does not appear to be associated with a worse prognosis.

Combination of two-hour post-endoscopic retrograde cholangiopancreatography amylase levels and cannulation times is useful for predicting post-endoscopic retrograde cholangiopancreatography pancreatitis

AIM To estimate the efficacy of 2 h post-endoscopic retrograde cholangiopancreatography(ERCP) serum amylase levels and other factors for predicting postERCP pancreatitis.METHODS This was a retrospective,single-center cohort study of consecutive patients who underwent ERCP from January 2010 to December 2013.Serum amylase levels were measured 2 h post-procedure,and patient- and procedure-related pancreatitis(PEP) risk factors wereanalyzed using a logistic model.RESULTS A total of 1520 cases(average age 72 ± 12 years,60% male) were initially enrolled in this study,and 1403 cases(725 patients) were ultimately analyzed after the exclusion of 117 cases.Fifty-five of these cases developed PEP.We established a 2 h serum amylase cutoff level of two times the upper limit of normal for predicting PEP.Multivariate analysis revealed that a cannulation time of more than 13 min [odds ratio(OR) 2.28,95%CI:1.132-4.651,P=0.0210] and 2 h amylase levels greater than the cutoff level(OR=24.1,95%CI:11.56-57.13,P<0.0001) were significant predictive factors for PEP.Forty-seven of the 55 patients who developed PEP exhibited 2 h amylase levels greater than the cutoff level(85%),and six of the remaining eight patients who developed PEP(75%) required longer cannulation times.Only 2 of the 1403 patients(0.14%) who developed PEP did not exhibit concerning 2 h amylase levels or require longer cannulation times.CONCLUSION These findings indicate that the combination of 2 h post-ERCP serum amylase levels and cannulation times represents a valuable marker for identifying patients at high risk for PEP.

Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography(ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use inthese complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.

Clinically diagnosed late-onset fulminant Wilson's disease without cirrhosis: A case report

A 64-year-old woman was referred to our hospital with jaundice of the bulbar conjunctiva and general fatigue. After admission, she developed hepatic encephalopathy and was diagnosed with fulminant hepatitis based on the American Association for the Study of Liver Disease(AASLD) position paper. Afterwards, additional laboratory findings revealed that serum ceruloplasmin levels were reduced, urinary copper levels were greatly elevated and Wilson's disease(WD)-specific routine tests were positive, but the Kayser-Fleischer ring was not clear. Based on the AASLD practice guidelines for the diagnosis and treatment of WD, the patient was ultimately diagnosed with fulminant WD. Then, administration of penicillamine and zinc acetate was initiated; however, the patient unfortunately died from acute pneumonia on the 28 th day of hospitalization. At autopsy, the liver did not show a bridging pattern of fibrosis suggestive of chronic liver injury. Here, we present the case of a patient with clinically diagnosed late-onset fulminant WD without cirrhosis, who had positive disease-specific routine tests.

Endoscopic submucosal dissection in early gastric cancer in elderly patients and comorbid conditions

The prognosis of early gastric cancer(EGC) is good if there is no concomitant lymph node metastasis. Therefore, the early detection of EGC is important to improve the prognosis of patients with gastric cancer. In Japan, 40% to 50% of all gastric cancers are EGC, and endoscopic submucosal dissection(ESD) is widely accepted as a local treatment for these lesions, particularly for large lesions that at one time were an indication for gastrectomy because of the difficulty of en-bloc resection. Consequently, this procedure can preserve the entire stomach and the patient's postoperative quality of life. ESD has become a general technique with improved procedures and devices, and has become the preferred treatment for EGC rather than gastrectomy. Therefore, ESD may demonstrate many advantages in patients who have several comorbidities, particularly elderly population, patients taking antithrombotic agents, or patients with chronic kidney disease, or liver cirrhosis. However, it is not yet clear whether patients with both EGC and comorbidities are feasible candidates for ESD and whether they would consequently be able to achieve a survival benefit after ESD. In this review, we discuss the clinical problems of ESD in patients with EGC and those comorbid conditions.

Immune checkpoint inhibitor-induced diarrhea/colitis: Endoscopic and pathologic findings

The indications of immune checkpoint inhibitors(ICPIs)for cancer treatment have rapidly expanded,and their use is increasing in clinical settings worldwide.Despite the considerable clinical benefits of ICPIs,frequent immune-related adverse events(ir AEs)have become nonnegligible concerns.Among ir AEs,ICPIinduced colitis/diarrhea is frequent and recognized not only by oncologists but also by gastroenterologists or endoscopists.The endoscopic findings show similarity to those of inflammatory bowel disease to a certain extent,particularly ulcerative colitis,but do not seem to be identical.The pathological findings of ICPI-induced colitis may vary among drug classes.They show acute or chronic inflammation,but it may depend on the time of colitis suggested by colonoscopy,including biopsy or treatment intervention.In the case of chronic inflammation determined by biopsy,the endoscopy findings may overlap with those of inflammatory bowel disease.Here,we provide a comprehensive review of ICPIinduced colitis based on clinical,endoscopic and pathologic findings.

Clinical problems with antithrombotic therapy for endoscopic submucosal dissection for gastric neoplasms

Endoscopic submucosal dissection(ESD) is minimally invasive and thus has become a widely accepted treatment for gastric neoplasms,particularly for patients with comorbidities.Antithrombotic agents are used to prevent thrombotic events in patients with comorbidities such as cardio-cerebrovascular diseases and atrial fibrillation.With appropriate cessation,antithrombotic therapy does not increase delayed bleeding in low thrombosis-risk patients.However,high thrombosisrisk patients are often treated with combination therapy with antithrombotic agents and occasionally require the continuation of antithrombotic agents or heparin bridge therapy(HBT) in the perioperative period.Dual antiplatelet therapy(DAPT),a representative combination therapy,is frequently used after placement of drug-eluting stents and has a high risk of delayed bleeding.In patients receiving DAPT,gastric ESD may be postponed until DAPT is no longer required.HBT is often required for patients treated with anticoagulants and has an extremely high bleeding risk.The continuous use of warfarin or direct oral anticoagulants may be possible alternatives.Here,we show that some antithrombotic therapies in high thrombosis-risk patients increase delayed bleeding after gastric ESD,whereas most antithrombotic therapies do not.The management of high thrombosis-risk patients is crucial for improved outcomes.

Clinical implications of diabetes in chronic liver disease:Diagnosis,outcomes and management,current and future perspectives

Diabetes mellitus(DM)is common in liver cirrhosis(LC).The pathophysiological association is bidirectional.DM is a risk factor of LC and LC is a diabetogenic condition.In the recent years,research on different aspects of the association DM and LC has been intensified.Nevertheless,it has been insufficient and still exist many gaps.The aims of this review are:(1)To discuss the latest understandings of the association of DM and LC in order to identify the strategies of early diagnosis;(2)To evaluate the impact of DM on outcomes of LC patients;and(3)To select the most adequate management benefiting the two conditions.Literature searches were conducted using Pub Med,Ovid and Scopus engines for DM and LC,diagnosis,outcomes and management.The authors also provided insight from their own published experience.Based on the published studies,two types of DM associated with LC have emerged:Type 2 DM(T2 DM)and hepatogenous diabetes(HD).High-quality evidences have determined that T2 DM or HD significantly increase complications and death pre and post-liver transplantation.HD has been poorly studied and has not been recognized as a complication of LC.The management of DM in LC patients continues to be difficult and should be based on drug pharmacokinetics and the degree of liver failure.In conclusion,the clinical impact of DM in outcomes of LC patients has been the most studied item recently.Nevertheless many gaps still exist particularly in the management.These most important gaps were highlighted in order to propose future lines for research.

Comparative study of esomeprazole and lansoprazole in triple therapy for eradication of Helicobacter pylori in Japan

AIM: To evaluate the efficacy and safety of esomeprazole-based triple therapy compared with lansoprazole therapy as first-line eradication therapy for patients with Helicobacter pylori (H. pylori) in usual post-marketing use in Japan, where the clarithromycin (CAM) resistance rate is 30%.

Reattachment of the Osteotomized Greater Trochanter in Hip Surgery Using an Ultrahigh Molecular Weight Polyethylene Fiber Cable: A Multi-Institutional Study

The purpose of this multicenter study was to evaluate the clinical performance of an ultrahigh molecular weight polyethylene (UHMWPE) fiber cable for re-attachment of the osteotomized greater trochanter in hip surgery. Included in the study were 85 hips that had undergone surgery with greater trochanter osteotomy, including 50 hip arthroplasty procedures and 35 hip osteotomies. The osteotomized greater trochanter was reattached using one or more UHMWPE fiber cables. The bone union and displacement of the greater trochanter were assessed in radiographs for up to 12 months after surgery. Non-union of the osteotomy site occurred in 4.7% of the cases. In approximately 90% of the cases, displacement was less than 2 mm at up to 12 months after surgery. The UHMWPE fiber cable was a good biomaterial for reattaching the osteotomized greater trochanter and may also be an option for osteosynthesis procedures.

Effectiveness and safety of chemotherapy for patients with malignant gastrointestinal obstruction:A Japanese populationbased cohort study

BACKGROUND The impacts of chemotherapy on patients with malignant gastrointestinal obstructions remain unclear,and multicenter evidence is lacking.AIM To evaluate the effectiveness and safety of chemotherapy in patients with unresectable malignant gastrointestinal obstructions.METHODS We conducted a multicenter retrospective cohort study that compared the chemotherapy group who received any chemotherapeutics after interventions,including palliative surgery or selfexpandable metal stent placement,for unresectable malignant gastrointestinal obstruction vs the best supportive care(BSC)group between 2014 and 2019 in nine hospitals.The primary outcome was overall survival,and the secondary outcomes were patency duration and adverse events,including gastrointestinal perforation and gastrointestinal bleeding.RESULTS In total,470 patients in the chemotherapy group and 652 patients in the BSC group were analyzed.During the follow-up period of 54.1 mo,the median overall survival durations were 19.3 mo in the chemotherapy group and 5.4 mo in the BSC group(log-rank test,P<0.01).The median patency durations were 9.7 mo[95% confidence interval(CI):7.7-11.5 mo]in the chemotherapy group and 2.5 mo(95%CI:2.0-2.9 mo)in the BSC group(log-rank test,P<0.01).The perforation rate was 1.3%(6/470)in the chemotherapy group and 0.9%(6/652)in the BSC group(P=0.567).The gastrointestinal bleeding rate was 1.5%(7/470)in the chemotherapy group and 0.5%(3/652)in the BSC group(P=0.105).CONCLUSION Chemotherapy after interventions for unresectable malignant gastrointestinal obstruction was associated with increased overall survival and patency duration.

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID- 19 pandemic

Background During the COVID-19 pandemic,decreased volumes of stroke admissions and mechanical thrombectomy were reported.The study’s objective was to examine whether subarachnoid haemorrhage(SAH)hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.Methods We conducted a cross-sectional,retrospective,observational study across 6 continents,37 countries and 140 comprehensive stroke centres.Patients with the diagnosis of SAH,aneurysmal SAH,ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases,10th Revision,codes.The 3-month cumulative volume,monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before(1 year and immediately before)and during the pandemic,defined as 1 March-31 May 2020.The prior 1-year control period(1 March-31 May 2019)was obtained to account for seasonal variation.Findings There was a significant decline in SAH hospitalisations,with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic,representing a relative decline of 22.5%(95%CI−24.3%to−20.7%,p<0.0001).Embolisation of ruptured aneurysms declined with 1170-1035 procedures,respectively,representing an 11.5%(95%CI−13.5%to−9.8%,p=0.002)relative drop.Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations,a 24.9%relative decline(95%CI−28.0%to−22.1%,p<0.0001).A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1%(95%CI 32.3%to 50.6%,p=0.008)despite a decrease in SAH admissions in this tertile.Interpretation There was a relative decrease in the volume of SAH hospitalisations,aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic.These findings in SAH are consistent with a decrease in other emergencies,such as stroke and myocardial infarction.