A Case of a Primiparous Woman Who Had Been Treated With Multimodal Therapy for Ovarian Dysgerminoma in Childhood / 日本農村医学会雑誌

Pregnancy and childbearing are important issues for female survivors of childhood, adolescent, and young adult (CAYA) cancer. Here, we report the case of a 38-year-old primiparous woman who had been treated with multimodal therapy for ovarian dysgerminoma in childhood. During junior high school, she had been admitted to our hospital complaining of abdominal distension, fever, and dyspnea. A massive abdominal tumor was found, and she was referred to a university hospital for treatment. Ovarian tumors suspected to be ovarian dysgerminoma were diagnosed, and right oophorectomy with lymph node dissection was performed. The left ovary was preserved. Postoperative histologic examination revealed ovarian dysgerminoma with class V ascites cytology, indicating Stage IIIc disease. The postoperative course was uneventful. Following surgery, she received bleomycin, etoposide phosphate, and cisplatin chemotherapy. Menarche occurred 12 years after surgery. She visited a gynecology clinic 24 years and 9 months after surgery because of suspected pregnancy. Pregnancy was confirmed, and she gave birth by vaginal delivery at a gestational age of 35 weeks + 1 day. Both the patient and child are now in good health. Fertility is an important consideration for CAYA cancer survivors. In cases of CAYA cancer, it is important to make treatment decisions together with patients with due consideration given to survival and fertility.

Difficulties and Countermeasures in Nursing Practice for Non-English-Speaking Foreign Patients with COVID-19 / 日本農村医学会雑誌

The purpose of this study was to clarify difficulties and countermeasures in nursing practice for foreign patients with COVID-19 who were non-English native speakers. A questionnaire was collected from 16 nurses in a COVID-19 ward. They cared for 13 non-English-speaking foreign patients from admission to discharge in the ward between May 2021 and June 2021. All nurses reported difficulties in communication related to collecting information from patients and explaining hospital care. For example, they could have simple conversations using a two-way translation device (POKETALK®) but could not understand detailed symptoms or complaints without an interpreter. Not much meaning could be inferred from a patient’s response of “OK”. The nurses reported that it was difficult to explain details of treatments, Japanese customs, and hospital rules. With the help of interpreters, they made hospital manuals and question cards in the patients’ native languages. In nursing care for foreign patients with COVID-19, it was helpful to provide explanations of Japanese customs and hospital rules before admission and to prepare hospital manuals and question cards in patients’ native languages.

Venous Thromboembolism in Patients with Gastrointestinal Cancers / 日本農村医学会雑誌

Venous thromboembolism (VTE) is a common complication in patients with cancer, particularly those with gastrointestinal cancers. In addition, patients with distant metastasis of gastrointestinal cancer often require palliative surgery. Here we report on the current status of VTE in patients with gastrointestinal cancers at our hospital, where we treated 20 patients with gastrointestinal cancers who developed VTE between January 2009 and December 2018. Nine patients had gastric cancer, 6 had colorectal cancer, 3 had biliary cancer, and 2 had pancreatic cancer. Fifteen of the 20 patients had distant metastasis as well. Median survival was 9 months, but VTE was not the direct cause of death in any patient. Although many of these patients had advanced cancer with distant metastasis, 16 still required gastrointestinal surgery. Our findings indicate that gastrointestinal surgeons need to be proficient in the diagnosis and treatment of VTE in patients with malignancy.

Effects of Highly Concentrated Enteral Nutrition on Nutritional Status and Bodyweight Maintenance in Chemotherapy-Treated Patients with Gastrointestinal Cancer / 日本農村医学会雑誌

The purpose of this study was to evaluate the effects of highly concentrated enteral nutrition (ENORAS®, Otsuka Pharmaceutical Factory, Tokushima, Japan; hereinafter, ED) on the maintenance of nutritional status and bodyweight in chemotherapy-treated patients with gastrointestinal cancer who received ED between July 2019 and January 2020. For 21 patients (15 men and 6 women, age range: 57-87 years old), we investigated serum albumin level, cholinesterase level, lymphocyte count, hemoglobin level, and bodyweight at baseline and after receiving ED. None of the patients showed any differences in albumin level, cholinesterase level, lymphocyte count, hemoglobin level, or bodyweight before and after receiving ED. Survivors had significantly favorable changes in cholinesterase level compared with non-survivors (p=0.0258). The group that received ED for 30 days or longer tended to show more favorable changes in bodyweight than the group that received ED for less than 30 days (p=0.0696). The group with stage I-III disease had more favorable changes in albumin level than the group with stage IV disease or recurrence (p=0.0932). Our results suggest that the ED is useful for helping to maintain nutritional status and bodyweight in chemotherapy-treated patients with gastrointestinal cancer.

Clinical Experience and Lessons of Coronavirus Disease 2019 (COVID-19) Treatment Early in the Pandemic at a Public Regional Core Hospital / 日本農村医学会雑誌

Coronavirus disease 2019 (COVID-19) has spread rapidly in Japan. The purpose of this study was to report the clinical experience of our COVID-19 patients early in the pandemic and lessons from our experience. An outpatient fever clinic was established on April 7. Admission of COVID-19 patients was started on July 23. Between April 7 and September 30, there were 364 walk-in outpatients and emergency patients with fever. Polymerase chain reaction test for SARS-CoV-2 RNA or COVID-19 antigen test were performed in all patients, and all results were negative. Twenty patients with COVID-19 were admitted to a newly established dedicated COVID-19 ward. They were discharged well. There were no cases of nosocomial infection at our hospital. Length of hospitalization was correlated with serum ferritin level at admission, serum CRP level at admission, and age. More than half the patients experienced psychological stress, and COVID-19 specialized nurses experienced some stress. It is essential to set up the medical system for COVID-19 according to the trends of the disease. Creation of our original database and our “problem notebook” were useful for treatment and care of COVID-19 patients as well as for mental care of nurses.

A Case of an Elderly Dementia Patient in Close Contact With COVID-19 Patients Who Was Hospitalized With Family Members With COVID-19 in the COVID-19 Ward / 日本農村医学会雑誌

A woman in her 80s was being treated for dementia. She lived in a four-generation household of 8 people. Her grandchild contracted COVID-19 and was admitted in another hospital. The 7 other family members were close contacts of the grandchild, and all of them except the woman with dementia developed COVID-19 within 3 days of onset in the grandchild. The woman’s PCR test for SARS-CoV-2 was negative. Her family thought that she could not live alone, but she was denied admission to other hospitals. Finally, she was admitted to our COVID-19 ward with her other family members at the family's request. After admission, she stayed in a room with family members, and COVID-19 treatment for her family and her care were performed with strict infection control measures in place. On hospital day 11, she and 5 family members had negative PCR test results for SARS-COV-2 and were discharged. With the growing number of dementia patients in Japan's aging society, there is the possibility that similar situations will occur increasingly often. This case suggests that recommended infection control measures are effective for preventing the spread of COVID-19 to people staying in the same room.

Questionnaire Survey of Medical Staff and Community Dwellers on End-of-life Care / 日本農村医学会雑誌

We conducted a questionnaire survey of 525 persons regarding end-of-life care (EoLC) between November and December 2017. A total of 495 individuals responded (response rate 94.3%). Respondents were grouped into either a medical staff (MS) group or community persons (CP) group. Significant differences were found between the MS and CP groups in implementing a family conference about EoLC (p＜0.05), but not in preparing documents about personal preferences for EoLC. There were significant differences between the groups in medical treatments in EoLC, for example, total parenteral nutrition, enteral nutrition via percutaneous endoscopic gastrostomy, and mechanical ventilation with intubation (p＜0.05). It is important that medical treatment in EoLC should meet the requirements of patients and their families. This study revealed differences in some aspects of EoLC between the MS and CP groups. Individuals should be supported in personally making decisions about their own EoLC.

Clinical Study of Mamushi Viper Bites in 35 Cases / 日本農村医学会雑誌

Mamushi is a species of pit viper distributed throughout Japan excluling the Ryukyu Islands and sighted from spring to autumn. It is estimated that about ten people dies in a year. It is important in the rural medicine because a lot of people are bitten in mountains and fields. A total of 35 cases of mamushi viper bite were treated from 1999 to 2006 in our hospital. The patients were 17 men and 18 women ranging in age from 7 to 80 years old (average: 60). Local swelling and pain were manifest in all the cases. Sixteen patients had systemic symptoms, and toxic effects commonly appeared in the eyes. The blood tests revealed elevated CPK levels in 24 patients (69%). The elevation correlated to the seriousness of the clinical symptoms. In accordance with our manual for mamushi viper bites, all patients were hospitalized after incision for exclusion of the toxin. The median length of time before the worst symptoms began to subside was 3 days. The median length of hospitalization stays was 7 days. It took long before the patients fully recovered. The severity of envenomation was different from patient to patient and one case needed intensive care. The median of treatment period was 31 days. The quick and appropriate primary care for the mamushi viper bits is important to prevent serious complications.

Perioperative Management to Prevent Postoperative Pulmonary Embolism in General Surgical Patients / 日本農村医学会雑誌

Recently, the incidence of pulmonary embolism (PE) after surgery began to increase in Japan and to prevent PE has become essentially important. During the period between July 2003 and August 2004, we placed 203 general surgical patients under our perioperative management using intermittent pneumatic compression (IPC) and compression stockings (CS). We evaluated the effect of our management on the prevention of postoperative PE in those patients. The incidence of PE, prognosis, complications, patient's complaints, cost-benefit were examined. No fatal PE occurred. One patient with low SpO2 had a chest pain and dyspnea but pulmonary scintigrams revealed no PE. Two other patients had contact dermatitis by CS and another patient using an epidural catheter suffered temporary paraplegia after heparin injection. The government has approved a fee for PE prophylaxis since April 2004. Our management using IPC and CS for PE prophylaxis after surgery proved to be an effective in reducing the risk of PE. However, we must take the atmost care in injecting heparin into patients with epidural catheters.

Evaluation of Quality of Life in Patients with Breast Cancer Treated with Chemotherapy / 日本農村医学会雑誌

Recently the evaluation of health-related quality of life (QOL) in cancer patients has become important in carrying out a treatment strategy. During a period between June and August 2004, we studied the QOL in 16 breast cancer patients with or without chemotherapy. The regimens of chemotherapy were EC (n=6), AT (n=1) and CMF (n=1). We made the Functional Assessment of Cancer Therapy Scale-General (FACT-G) in all patients. The patients treated without chemotherapy were superior to those with chemotherapy with respect to physical and emotional well-being (p<0.05). There were no differences in social well-being and relationship to families between the two groups. The patients treated without chemotherapy made significantly higher scores in the basic activities of daily living than those with chemotherapy (p<0.05). Compared with patients receiving chemotherapy, patients treated without chemotherapy had better quality of life (p<0.05). We concluded that it was important for us to assist in decision making about treatment and supportive care needs.

Surgical Treatment of Multiple Aneurysms / 日本心臓血管外科学会雑誌

Morphology, location, timing of operation, and complications of multiple aortic aneurysms were investigated in 14 patients (10 men and 4 women with a mean age of 66 years). The locations of the aneurysms were as follows: aortic arch and thoracoabdominal aorta in 1, aortic arch and infrarenal abdominal aorta in 6, descending thoracic aorta and suprarenal abdominal aorta in 1, descending thoracic aorta and infrarenal abdominal aorta in 5, and thoracoabdominal aorta and infrarenal abdominal aorta in 1. Thoracic aortic aneurysms had a mean diameter of 63±13mm. The mean diameter of the abdominal aortic aneurysms was 54±13mm. In 1 patient, thoracoabdominal and infrarenal abdominal aortic aneurysms were operated on simultaneously. Eight patients, 5 with aneurysms of the aortic arch and infrarenal abdominal aorta, 2 with aneurysms of the descending aorta and infrarenal abdominal aorta, and 1 with aneurysms of the aortic arch and thoracoabdominal aorta, underwent two-staged operation. Aortic arch aneurysm was operated first in 3 patients, and abdominal aortic aneurysm in 5. Postoperative complications included spinal cord injury in 1 patient, bowel necrosis in 1, renal impairment in 2, respiratory impairment in 2, and hepatic impairment in 1. There was no perioperative death. Three late deaths occurred. Two staged operation is better for multiple aortic aneurysms. The first operation should be performed for the larger aneurysm.

Quality of Life after Thoracic or Thoraco-Abdominal Aneurysmectomy / 日本心臓血管外科学会雑誌

We investigated the quality of life (QOL) after thoracic or thoraco-abdominal aneurysmectomy in patients who had undergone the procedure within the past 15 years. We compared preoperative to postoperative performance status (PS). Defining PS in the following manner: one increase in that PS grade indicated mild worsening while an increase is by 2 or more indicated severe worsening. Maintenance was indicated by no change of PS after surgery. The QOL maintenance rate was calculated based on the following formula.<br>QOL maintenance(%)=No. of no change case/No. of operated cases-No. of death×100<br>There were a total of 74 cases in whom follow-ups could be carried out after surgery. Among them, there were ascending and aortic arch aneurysms in 19 cases, descending aortic aneurysms in 20 cases, dissecting aneurysms in 27 cases and thoraco-abdominal aortic aneurysms in 8 cases. The QOL maintenance rate in the type B dissecting aneurysms was comparatively high (85.7%). There were cases of severe worsening of PS in the ascending and aortic arch aneurysms and type A dissecting aneurysms and the QOL maintenance rate was 50% in each other. We should obtain high operative results due to improve the QOL maintenance rate, and devise the operative procedure without functional disorders of the organs after surgery.

Changes of Hemodynamic and Blood Chemical Mediators after Aortic Clamping in Infrarenal Abdominal Aortic Aneurysmectomy / 日本心臓血管外科学会雑誌

Changes of hemodynamics and chemical mediators before and after aortic clamping were investigated in 12 patients who underwent infrarenal abdominal aortic aneurysmectomy. Patients were divided into two groups; one with an aortic clamping time greater than 1 hour (the long group) and the other with aortic clamping time less than 1 hour (the short group). Cardiac output, mean pulmonary arterial pressure (MPAP), extravascular thermal volume (ETV), polymorphonuclear elastase (PMN-E), α₁ trypsin inhibitor (α₁-TI) superoxide dismutase (SOD), urine <i>N</i>-acetyl-β-D-glucosaminidase (NAG), were measured before and immediately after aortic clamping, immediately after, 1 and 4 hours after aortic declamping. In addition, serum GOT, GPT, creatinine and BUN were measured before and 1, 3 and 7 day after operation. These levels were expressed as ratios of the level before aortic clamping and operation. The MPAP ratio immediately after aortic clamping was 0.83±0.06 in the long group and 0.99±0.08 in the short group. There was statistical significant difference in the MPAP between both groups (<i>p</i><0.01). In contrast, there was no significant difference in the cardiac output or ETV between the two groups. The PMN-E ratio immediately after aortic declamping was 2.24±0.81 in the long group and 1.19±0.45 in the short group. These ratios increased at 1 and 4 hours after aortic declamping. The PMN-E ratio following aortic clamping in the long group was greater than those in the short group (<i>p</i><0.05). The SOD at 1 hour after aortic declamping was 0.78±0.13 in the long group and 1.01±0.11 in the short group (<i>p</i><0.05). The NAG ratio immediately and at 1 hour after aortic declamping was significantly higher in the long group when compared with the short group (<i>p</i><0.01, 0.1). Serum GOT, GPT, creatinine and BUN ratios showed no change through out this study. There was an increase in protease and a decrease of free radical scavengers in the long group. These findings are commonly known to be linked with organ damage. Through the findings of this study, we suggest that clamping time should be minimized; thus reducing the possible chance of postoperative organ damage.

Comparison between Arteriosclerotic Thrombosis and Embolism in Acute Arterial Occlusive Disease / 日本心臓血管外科学会雑誌

During the period between January 1975 and April 1991, 37 patients with acute arterial occulusion of the extremities were admitted to our department and were classified into 2 groups according to their causative factors, including thrombosis and embolism. Among 16 thrombosis patients with involvement of 17 limbs, 4 patients died and 6 limbs were amputated at the time of discharge. On the contrary, among 21 embolism patients with involvement of 25 limbs, 2 patients died and only one limb was amputated. Sixteen of 17 limbs with thrombosis were operated on. Arterial reconstruction was carried out initially on 5 limbs, resulting in successful limb salvage; 3 of 6 limbs which had undergone thrombectomy initially were occluded again soon after the procedure. In the end, 1 limb had to be amputated. On the other hand, 22 of 25 limbs were operated on. Three arterial reconstructions, 18 embolectomies and 1 amputation were carried out initially. All arterial reconstructions and embolectomies were successful. From these results, it was concluded that arterial reconstruction must be done initially for thrombosis patients. For the embolism patients, embolectomy is preferable.

Usefulness of Treadmill Test for Determination of Degree of Intermittent Claudication / 日本心臓血管外科学会雑誌

The degree of intermittent claudication is difficult to evaluate objectively; therefore, the therapeutic efficiency of a drug is difficult to test in patients suffering from intermittent claudication. The purpose of this paper is to know whether treadmill test is useful to evaluate objectively the degree of intermittent claudication. 20 patients suffering from a peripheral arterial occlusive disease with intermittent claudication (Stage II) were investigated. PGE₁ incorporated in lipid microspheres (Lipo PGE₁) was infused (10μg/day) with one shot on 7 consecutive days into the forearm vein of patients. Painfree walking distance and maximum walking distance were measured on treadmill (3.0km/h, 5% incline). Brachial systolic pressure and ankle pressures were measured before and after exercise, and ankle/arm pressure ratio and ankle pressure difference between the pre-exercise and post-exercise values were calculated. All measurements were performed before and 7 days after beginning of treatment. Painfree walking distance was prolonged from 72.5±41.4m before treatment to 92.0±53.7m after treatment, with significant difference (<i>p</i><0.01). However, no significant changes of ankle/arm pressure ratio, ankle pressure difference and maximum walking distance were observed. It is concluded that measurement of painfree walking distance on treadmill was useful to evaluate objectively the degree of intermittent claudication.