藤田 英雄

It is of utmost importance to minimize the door-to-balloon time for the initial treatment of ST-elevation acute myocardial infarction. In this case report, we made all kinds of efforts to minimize procedures in the emergency department (ED minimization) as well as in the catheter laboratory without sacrificing safety.

BACKGROUND: Diet and fluid restrictions that need continuous self-management are among the most difficult aspects of dialysis treatment. Smartphone applications may be useful for supporting self-management. OBJECTIVE: Our objective is to investigate the feasibility and usability of a novel smartphone-based self-management support system for dialysis patients. METHODS: We developed the Self-Management and Recording System for Dialysis (SMART-D), which supports self-monitoring of three mortality-related factors that can be modified by lifestyle: interdialytic weight gain and predialysis serum potassium and phosphorus concentrations. Data is displayed graphically, with all data evaluated automatically to determine whether they achieve the values suggested by the Japanese Society for Dialysis Therapy guidelines. In a pilot study, 9 dialysis patients used SMART-D system for 2 weeks. A total of 7 of them completed questionnaires rating their assessment of SMART-D's usability and their satisfaction with the system. In addition, the Kidney Disease Quality of Life scale was compared before and after the study period. RESULTS: All 9 participants were able to use SMART-D with no major problems. Completion rates for body weight, pre- and postdialysis weight, and serum potassium and phosphorus concentrations were, respectively, 89% (SD 23), 95% (SD 7), and 78% (SD 44). Of the 7 participants who completed the usability survey, all were motivated by the sense of security derived from using the system, and 6 of the 7 (86%) reported that using SMART-D helped improve their lifestyle and self-management. CONCLUSIONS: Using SMART-D was feasible, and the system was well regarded by patients. Further study with larger scale cohorts and longer study and follow-up periods is needed to evaluate the effects of SMART-D on clinical outcomes and quality of life.

Coronary spasm is abnormal contraction of an epicardial coronary artery resulting in myocardial ischemia. Coronary spasm induces not only depressed myocardial contractility, but also incomplete myocardial relaxation, which leads to elevated ventricular filling pressure. We herein report the case of a 55-year-old woman who had repeated acute heart failure caused by coronary spasm. Acetylcholine provocation test with simultaneous right heart catheterization was useful for the diagnosis of elevated ventricular filling pressure as well as coronary artery spasm. We should add coronary spasm to a differential diagnosis for repeated acute heart failure.

<p>Acute symptomatic deep vein thrombosis (DVT) is usually managed by intravenous heparin and oral warfarin. Recently, direct oral anticoagulants (DOAC) have been introduced for the treatment of acute DVT. DOAC may be useful for very elderly patients who live in rural areas, where medical resources are limited. An 83-year-old woman presented to our clinic with left leg edema. Contrast enhanced computed tomography showed massive deep vein thrombosis in her left internal iliac vein. We diagnosed her with acute deep vein thrombosis. Since she refused to be hospitalized, we treated her with rivaroxaban as an outpatient. She had a good clinical course without hospitalization or an adverse event. DOAC may be useful for very elderly patients in rural areas.</p>

OBJECTIVES: To examine the prevalence of the willingness of patients with diabetes to use a self-management tool based on information and communication technology (ICT) such as personal computers, smartphones, and mobile phones; and to examine the patient characteristics associated with that willingness. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional interview survey of 312 adults with diabetes at a university hospital in an urban area in Japan. Participants were classified into 2 groups: those who were willing to use an ICT-based self-management tool and those who were unwilling. Multiple logistic regression analysis was used to identify factors associated with the willingness, including clinical and social factors, current use of ICT, self-management practices, self-efficacy, and diabetes-related emotional distress. RESULTS: The mean age of the 312 participants was 66.3 years (SD=11.5) and 198 (63%) were male. Most of the participants (93%) had type 2 diabetes. Although only 51 (16%) currently used ICT-based self-management tools, a total of 157 (50%) expressed the willingness to use such a tool. Factors associated with the willingness included: not having nephropathy (OR=2.02, 95% CI 1.14 to 3.58); outpatient visits once a month or more (vs less than once a month, OR=2.13, 95% CI 1.13 to 3.99); current use of personal computers and/or smartphones (OR=4.91, 95% CI 2.69 to 8.98); and having greater diabetes-related emotional distress (OR=1.10, 95% CI 1.01 to 1.20). CONCLUSIONS: Approximately half of the patients showed interest in using an ICT-based self-management tool. Willing patients may expect ICT-based self-management tools to complement outpatient visits and to make self-management easier. Starting with patients who display the willingness factors might optimize programs based on such tools.

Compared to acute myocardial infarction (AMI) with single vessel disease (SVD) or double vessel disease (DVD), AMI with triple vessel disease (TVD) is associated with higher mortality. The aim of this study was to identify the determinants of in-hospital death in AMI with TVD. We identified AMI patients with TVD in our tertiary medical center between January 2009 and December 2014. Baseline patient characteristics including laboratory data, echocardiograms, and coronary angiograms were collected from our hospital records. We divided our study population into a survivor group and non-survivor group. Multivariate stepwise logistic regression analysis was performed to identify the determinants of in-hospital death. A total of 138 AMI patients with TVD were identified and included as the final study population. Fifteen patients died during the hospitalization (mortality rate, 10.9%). Mean systolic blood pressure (134 ± 27 mmHg) was significantly greater in the survivor group compared with the non-survivor group (114 ± 31 mmHg) (P = 0.02). The prevalence of shock on admission was significantly less in the survivor group (15.4%) than in the non-survivor group (66.7%) (P < 0.001). Multivariate stepwise logistic regression analysis revealed that shock status on admission (OR 11.50, 95% CI 3.21-41.14, P < 0.001), the left anterior descending artery (LAD) as the infarct related artery (IRA) (OR 3.83, 95% CI 1.04-14.09, P = 0.04), and serum albumin on admission (OR 0.26, 95% CI 0.08-0.84, P = 0.02) were significantly associated with in-hospital death. In conclusion, shock status on admission, the LAD as the IRA, and a low serum albumin level were the determinants of in-hospital death in AMI patients with TVD.

BACKGROUND: The usage of rotational atherectomy (RA) is growing in the current percutaneous coronary intervention (PCI) because of the expansion of PCI indication to more complex lesions. However, the complications after RA have been linked to procedure-related morbidity and mortality. The purpose of this study was to investigate the incidence and determinants of complications in RA using a large nationwide registration system in Japan (J-PCI). METHODS AND RESULTS: The primary composite outcome of this study was defined as the occurrence of in-hospital death, cardiac tamponade, and emergent surgery after RA. A total of 13 335 RA cases (3.2% of registered PCI cases) were analyzed. The composite outcome was observed in 175 cases (1.31%) and included 80 in-hospital deaths (0.60%), 86 tamponades (0.64%), and 24 emergent surgeries (0.18%). The clinical variables associated with occurrence of the composite outcome were age (odds ratio [OR] 1.03 per unit increment, 95% confidence interval [CI] 1.02-1.05), impaired kidney function (OR 1.59, 95% CI 1.15-2.19), previous myocardial infarction (OR 1.69, 95% CI 1.21-2.35), emergent PCI (OR 4.02, 95% CI 1.66-8.27), and triple-vessel disease (versus single-vessel disease: OR 2.17, 95% CI 1.43-3.28). Notably, institutional volume of RA cases was inversely associated with the composite outcomes (high- versus low-volume institution: OR 0.56, 95% CI 0.36-0.89). CONCLUSIONS: The reported incidence of important procedure-related complication rate was 1.3%, with each component ranging between 0.2% and 0.6% in J-PCI. Its determinants were both patient related (age, impaired kidney function, and previous myocardial infarction) and procedure related (emergent procedures, number of diseased vessels, and institutional volume of RA).