急性期治療を受ける高齢脳梗塞患者のせん妄アセスメントに関する研究 : 高度看護実践者の入院初期における観察点

目的：高度看護実践者の高齢脳梗塞患者の入院時におけるせん妄アセスメントに関する観察点を明らかにすることである。方法：質的記述的研究デザインを用いた。対象者は老人看護専門看護師、認知症看護認定看護師、高齢脳梗塞患者の看護経験豊富な熟練看護師等の6名であった。研究者らが作成した事例に沿って、せん妄に関する観察点について半構造的面接を行った。分析は逐語録から観察点を切り取り、類似性の高いものをグルーピングした。結果：高齢患者の脳梗塞による神経症状、全身状態、入院後の生活機能、心理の変化、入院前の生活、生活史を観察し、家族からは神経症状、入院前の生活、人となりに関する情報を得ていた。考察：入院時から身体面の他、これまでの生活、人物像に関する観察を行い、家族からの情報を高齢患者の入院前後の変化の鮮明化に活用していた。それらは個別性のあるせん妄ケアの実践に反映されていると考えられた。Purpose: To identify advanced nursing practitioners’ observations regarding delirium assessment during hospitalization among older adult stroke patients.Methods: A qualitative descriptive research design was used. The six participants included a Certified Nurse Specialist of Gerontological Nursing, a Certified Nurse of Dementia Nursing, and a skilled nurse with extensive experience in caring for older adult stroke patients. Semi-structured interviews were conducted on observations about delirium according to a case study developed by the researchers. We analyzed the observations in the verbatim transcripts and grouped highly similar ones.Results: The nurses’ observations were related to neurological symptoms due to cerebral infarction, general conditions, life functions after hospitalization, psychological changes, lifestyle before hospitalization, and life history; Meanwhile, they obtained information from family members related to neurological symptoms, life before hospitalization, and personal characteristics.Discussion: The information obtained from family members was used to clarify changes, before and after hospitalization, indicating a practice of individualized delirium care

CSC with and without steroids

We investigated the rates of the use of steroids in Japanese central serous chorioretinopathy (CSC) cases and differences in the characteristics of CSC with and without steroids. A total of 538 eyes of 477 patients diagnosed with CSC, with 3 months or more of follow-up between April 2013 and June 2017 at 8 institutions. Patients with CSC with more than 3 months of follow-up were identified by OCT and fluorescein angiography at 8 institutions. Data collected included patient demographics, history of corticosteroid medication and smoking, spherical errors, findings of angiography, subfoveal choroidal thickness, and changes through the follow-up period. Differences in these findings were analyzed in cases with and without corticosteroid treatment. Among the 477 patients (344 men,133 women), 74 (15.5%) (39 men, 35 women) underwent current or prior steroid treatment. Cases with steroids were higher age (p = 0.0403) and showed no male prevalence, more bilateral involvement (p < 0.0001), and the affected eyes had multiple pigment epithelial detachment (p <0.0001), more fluorescein leakage sites (p < 0.0001), greater choroidal thickness (p = 0.0287) and a higher recurrence rate (p = 0.0412). Steroids can cause severer CSC through an effect on choroidal vessels and an impairment of retinal pigment epithelium

AMD-associated submacular hemorrhage

Purpose To investigate the clinical features, treatment options, and visual outcomes of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD). Design A retrospective, observational case series. Methods Setting: Multicenter institutional setting. Patient Population: A total of 127 patients (127 eyes; 88 men, 39 women; (mean age, 74.2 years)) diagnosed with AMD-associated SMHs exceeding 2 disc diameters involving the fovea. Observation: The AMD types, previous treatments, treatment options, anatomic findings, and best-corrected visual acuity (BCVA) were assessed. Main Outcome Measures: Clinical features, treatment options, and visual outcomes of SMHs secondary to nAMD. Results Thirty-two eyes had typical AMD, 94 eyes polypoidal choroidal vasculopathy (PCV), and one eye retinal angiomatous proliferation. Eighty-five eyes were treatment-naïve; 42 eyes were treated previously: anti-vascular endothelial growth factor (VEGF) therapy (n = 26), photodynamic therapy (n = 3), and combined therapy (n = 13). Treatment of SMHs included vitrectomy (36 eyes), pneumatic displacement (49 eyes), and anti-VEGF monotherapy (42 eyes). The final BCVA improved significantly in treatment-naïve cases from 0.86 to 0.62 logarithm of the minimal angle of resolution (logMAR) unit (Snellen equivalent from 20/145 to 20/83) and from 0.80 to 0.56 (Snellen equivalent from 20/126 to 20/73) in PCV cases. Meanwhile, the BCVA logMAR values improved from 1.15 to 0.75 (Snellen equivalent from 20/283 to 20/112) and from 0.87 to 0.63 (Snellen equivalent from 20/148 to 20/85) in eyes that underwent vitrectomy or pneumatic displacement, respectively. In eyes with BCVAs between 20/133 to 20/40 at SMH onset, the final VA in the pneumatic displacement group was better than in the anti-VEGF monotherapy group. One eye had a retinal detachment and 1 eye had a macular hole in the vitrectomy group, and 5 eyes had a vitreous hemorrhage in the pneumatic displacement group. Conclusions The recommended treatment for SMHs secondary to nAMD exceeding 2 disc area and with BCVA below 20/40 is vitrectomy or pneumatic displacement for visual improvement

A multicenter survey for submacular hemorrhage

Purpose To evaluate the clinical characteristics, treatment trends, and visual prognosis of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) and retinal arterial macroaneurysm (RAM). Methods This retrospective study enrolled 187 Japanese patients with SMH at 10 institutions from 2015 to 2018. Medical records including SMH etiology, best-corrected visual acuity (BCVA), fundus photographs, optical coherence tomography images, and selected treatments were analyzed. Results Major causes of SMH were typical nAMD (tnAMD) (18%), polypoidal choroidal vasculopathy (PCV) (50%) and RAM (29%). Age, male/female ratio, baseline BCVA, central retinal thickness, and involved retinal layers were significantly different between etiologies (all P<0.0001). Treatment with anti-vascular endothelial growth factor drugs with and without intravitreal gas injection was chosen for half of eyes in the tnAMD and PCV groups, whereas vitrectomy was performed in 83.7% of eyes with RAM. The final BCVA improved significantly from baseline in the PCV and RAM groups (P = 0.0009, P<0.0001) and final BCVA was significantly better in the PCV group at a level similar to the other groups (P = 0.0007, P = 0.0008). BCVA improvement from baseline was significantly greater in the RAM group compared with the tnAMD (P = 0.0152) and PCV (P = 0.017) groups. Multivariate analysis revealed better final BCVA was significantly associated with younger age (P = 0.0054), better baseline BCVA (P = 0.0021), RAM subtype (P = 0.0446), and no tnAMD (P = 0.001). Conclusions The characteristics of, and treatment strategy for, SMH were different between the underlying diseases. Anti-vascular endothelial growth factor treatment with or without expansile gas was mainly chosen for SMH in tnAMD and PCV, whereas vitrectomy with gas was the most common treatment for RAM, and the higher rate for vitrectomy might result in the greater BCVA improvement in the RAM group than in the other groups. Final BCVA was better in PCV, RAM, and tnAMD, in that order, because patients with PCV were younger and had better baseline BCVA

先輩が後輩を支援する「エルダー活動」を基礎ゼミナールに導入した試み

看護学部において、先輩である2年生が後輩である新入生を支援する「エルダー活動」を、1年前期に履修する科目「基礎ゼミナール」において導入し、その実践と期待される効果、今後の構想を報告した。本活動の目的は、新入生が早期に大学生活に慣れ、有意義な学生生活を送れるように支援すること、新入生への学習支援および在学生のリーダーシップ向上の一方法として導入し、双方の学力向上を目指すこと、共立女子大学看護学部の特色のひとつとなるような仕組みづくりを目指すこと、である。本活動の効果は、エルダー、学習者双方のほかに、コーディネイトする教員、学部にとってももたらされるものと期待される。課題として、エルダーの雇用、募集に関すること、エルダーの質の担保のための方法の整備、活動のルール作り、などが考えられた

看護系大学生の領域別実習における不安、達成感、自己効力感の関連

某看護系大学生における実習前後での不安、および実習後の達成感、看護実践への自己効力感（積極的行動、失敗不安）の関連性を明らかにするため、実習前と後に対象者に質問紙調査を行い、以下の結果を得た。（1）実習前の状態不安得点が高不安群に属したのは全体の26.5%、超高不安群は69.4% であった。（2）実習後の状態不安得点が高不安群に属したのは全体の28.6%、超高不安群は24.5% であった。（3）状態不安得点は実習前に比べて実習後で有意に低下した。（4）実習後の状態不安と実習後の達成感、実習後の状態不安と積極的行動、積極的行動と失敗不安とに有意な相関を認めた。以上から、実習前の看護学生の状態不安は高いが、実習後には低下していること、実習後の状態不安が低い看護学生は、実習の達成感や看護実践への自己効力感が高い傾向にあることが分かった。実習を通して看護学生の達成感や看護実践への自己効力感が高まるような教育的支援の必要性が示唆された。A questionnaire survey was conducted with nursing students of a certain university before and after nursing student\u27s clinical practicum in order to clarify the relationships among anxiety (STAI), sense of accomplishment, and self-efficacy(GSES: Proactive behavior, Fear of failure) in nursing practice.The following results were obtained. (1) Before the practicum, the high score cases of state anxiety were 25.6%, and the specially high score cases of state anxiety were 69.4%. (2) After the practicum, the high score cases of state anxiety were 28.6%, and the specially high score cases of state anxiety were 24.5%. (3) The mean value of the pre-practicum state anxiety significantly decreased than that of the post-practicum state anxiety. (4) After the practicum, between the state anxiety and "Sense of accomplishment", between the state anxiety and "Proactive behavior (GSES)", and between "Proactive behavior (GSES)" and "Fear of failure (GSES)", significant correlations were found respectively.A significant correlation was observed between post-practicum state anxiety and "Sense of accomplishment", post-practicum state anxiety and "Proactive behavior (GSES）", "Proactive behavior (GSES）" and "Fear of failure (GSES)".The above results indicate a post-practicum reduction in the pre-practicum high state anxiety in nursing students. Also the low state anxiety score indicates that students at the post-practicum tend to be high self-efficacy and the sense of accomplishment.The current results are indicative of the importance of educational support to nursing students that increases sense of accomplishment and self-efficacy in nursing practice obtained through clinical practicum

A Single Nucleotide Polymorphism within the Acetyl-Coenzyme A Carboxylase Beta Gene Is Associated with Proteinuria in Patients with Type 2 Diabetes

It has been suggested that genetic susceptibility plays an important role in the pathogenesis of diabetic nephropathy. A large-scale genotyping analysis of gene-based single nucleotide polymorphisms (SNPs) in Japanese patients with type 2 diabetes identified the gene encoding acetyl-coenzyme A carboxylase beta (ACACB) as a candidate for a susceptibility to diabetic nephropathy; the landmark SNP was found in the intron 18 of ACACB (rs2268388: intron 18 +4139 C > T, p = 1.4×10−6, odds ratio = 1.61, 95% confidence interval [CI]: 1.33–1.96). The association of this SNP with diabetic nephropathy was examined in 9 independent studies (4 from Japan including the original study, one Singaporean, one Korean, and two European) with type 2 diabetes. One case-control study involving European patients with type 1 diabetes was included. The frequency of the T allele for SNP rs2268388 was consistently higher among patients with type 2 diabetes and proteinuria. A meta-analysis revealed that rs2268388 was significantly associated with proteinuria in Japanese patients with type 2 diabetes (p = 5.35×10−8, odds ratio = 1.61, 95% Cl: 1.35–1.91). Rs2268388 was also associated with type 2 diabetes–associated end-stage renal disease (ESRD) in European Americans (p = 6×10−4, odds ratio = 1.61, 95% Cl: 1.22–2.13). Significant association was not detected between this SNP and nephropathy in those with type 1 diabetes. A subsequent in vitro functional analysis revealed that a 29-bp DNA fragment, including rs2268388, had significant enhancer activity in cultured human renal proximal tubular epithelial cells. Fragments corresponding to the disease susceptibility allele (T) had higher enhancer activity than those of the major allele. These results suggest that ACACB is a strong candidate for conferring susceptibility for proteinuria in patients with type 2 diabetes

Upregulation of ANGPTL6 in mouse keratinocytes enhances susceptibility to psoriasis

Psoriasis is a chronic inflammatory skin disease marked by aberrant tissue repair. Mutant mice modeling psoriasis skin characteristics have provided useful information relevant to molecular mechanisms and could serve to evaluate therapeutic strategies. Here, we found that epidermal ANGPTL6 expression was markedly induced during tissue repair in mice. Analysis of mice overexpressing ANGPTL6 in keratinocytes (K14-Angptl6 Tg mice) revealed that epidermal ANGPTL6 activity promotes aberrant epidermal barrier function due to hyperproliferation of prematurely differentiated keratinocytes. Moreover, skin tissues of K14-Angptl6 Tg mice showed aberrantly activated skin tissue inflammation seen in psoriasis. Levels of the proteins S100A9, recently proposed as therapeutic targets for psoriasis, also increased in skin tissue of K14-Angptl6 Tg mice, but psoriasis-like inflammatory phenotypes in those mice were not rescued by S100A9 deletion. This finding suggests that decreasing S100A9 levels may not ameliorate all cases of psoriasis and that diverse mechanisms underlie the condition. Finally, we observed enhanced levels of epidermal ANGPTL6 in tissue specimens from some psoriasis patients. We conclude that the K14-Angptl6 Tg mouse is useful to investigate psoriasis pathogenesis and for preclinical testing of new therapeutics. Our study also suggests that ANGPTL6 activation in keratinocytes enhances psoriasis susceptibility

Impact of severe coronary disease associated or not associated with diabetes mellitus on outcome of interventional treatment using stents: Results from HERZ (heart research group of Kanazawa) analyses

金沢大学医薬保健研究域医学系Percutaneous coronary intervention (PCI) using a drug-eluting stent (DES) leads to less re-stenosis than PCI using a bare metal stent (BMS), however there is still controversy whether use of a DES for severe coronary disease leads to an acceptable outcome in patients with diabetes mellitus (DM). In this study 8159 lesions were treated in 6739 patients (mean age 68.9 years) with coronary artery disease. Use of a DES significantly decreased the re-stenosis rate compared with BMS in both DM (9.6% versus 21.3%) and non-DM (9.5% versus 17.1%) patients. The re-stenosis rate was significantly higher in DM than in non-DM patients in the BMS group but not in the DES group. There was no statistically significant difference in event-free survival after stenting of patients with left main coronary artery (LMCA) disease between the BMS and DES groups. It was concluded that, compared with BMS, DES reduced re-stenosis in patients with DM, however, we advise careful treatment after using DES for severe coronary disease, including LMCA lesions, in patients with DM. © 2011 Field House Publishing LLP