JACR2018Abstract Submission Form

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Top Author (presenting author): Please input without using the umlaut. (e.g., ä->ae)
Occupation
Age
Family Name
First Name
Middle Initial
JACR Membership Number
(Please put “99” for pending registration or “88” for non-member)
Affiliation: Department and Institution/Company
(e.g. Department of XXX, University of XXX, Japan) / (1)
Zip (Postal) Code
Address
Country
Phone No. with National Code
(e.g. +81-3-1234-5678)
Fax No. with National Code
(e.g. +81-3-1234-5678)
E-mail Address
List of Co-authors’ Affiliations: Please list up all affiliations your co-authors belong to.
(e.g., Department of XXX, University of XXX, Japan)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Co-authors’ Information: First Name, Last Name, JACR Membership Number, AffiliationNumber from the List above, Country(e.g., Taro, Yamada, 123456, (3), Japan)
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Abstract Title: 200 characters or less

Abstract Category：（Select one、please check the box below）

check / No. / Category Name
☐ / 1 / Ischemic heart disease
☐ / 2 / Valuvular disease
☐ / 3 / Heart failure/ Cardiomyopathy
☐ / 4 / Cardiac surgery/ Vascular surgery
☐ / 5 / Aortic disease/ Perivascular disease
☐ / 6 / Pulmonary hypertension/ Pulmonary circulation
☐ / 7 / Ventricular assist device/ Heart transplantation
☐ / 8 / Arrhythmia/ Cardiac devices/ Cardiac resynchronization therapy
☐ / 9 / Chronic kidney disease/ End stage renal disease
☐ / 10 / Lung disease/ pulmonary rehabilitation/ Sleep apnea syndrome/ Mechanical ventilation
☐ / 11 / Orthopedic disorders/ Cerebrovascular complication
☐ / 12 / Sarcopenia/ Fraility
☐ / 13 / Aging/ Gender/ Elderly
☐ / 14 / Coronary risk factor/ Diabetes/ Dislipidemia/ Aherosclerosis/ Obesity/Metabolic syndrome
☐ / 15 / Mental and psychological disorder
☐ / 16 / Exercise test/ Gas analysis
☐ / 17 / Exercise physiology/Pulmonary physiology
☐ / 18 / Cardiac/ Vascular function
☐ / 19 / Skeletal muscle function/ Skeletal muscle metabolism
☐ / 20 / Autonomic nervous system/ Neurohumoral factor
☐ / 21 / Basic science research/ Translational research
☐ / 22 / Modes of exercise training/ Exercise prescription
☐ / 23 / Physical therapy/ADL
☐ / 24 / Acute phase of cardiac rehabilitation/ Early intervention
☐ / 25 / Maintenance phase of cardiac rehabilitation
☐ / 26 / Non-exercise based therapy/ Newly invented intervention/ New technology
☐ / 27 / Patient education/ Counseling/ Smoking cessation
☐ / 28 / Nutritional therapy/ Nutritional counselling/ Supplement
☐ / 29 / Medication consultation/ Medication compliance
☐ / 30 / Adherence in cardiac rehabilitation
☐ / 31 / Disease management program/ Preventing hospital readmissions
☐ / 32 / Management of cardiac rehabilitation/ Inter-professional work
☐ / 33 / Regional alliances/ Home health care
☐ / 34 / Medical safety management/ Staff training programs/ Team Medicine
☐ / 35 / Medical fee schedule/ Health economics/ Health care system
☐ / 36 / Primary prevention/ Epidemiology
☐ / 37 / Others
Use of figure/table: Only one figure/ table is acceptable.
☐ YES Please attach it to your E-mail with this form. / ☐NO
Abstract: 250 words or less. The space below may not contain any figures or tables.

COI Self-Disclosure

  • Please disclose COI status and name of company or organization involved with the subject matter of your presentation topic.
  • COI status must be disclosed for the preceding three year from the time of abstract submission.

However, concerning items 6 and 7,if clinical fundingor scholarship funds related to the publication of research results are provided by a business, organization or group, to the author, or his/her affiliated department or field, these must also be disclosed.

Type / Applicable or related COI / If yes, list the name(s) of company or organization
1 / Consultancy
Annual income from a single company or organization, as an officer or consultant, which exceeds an annual total of 1,000,000 yen / Author
Yes ☐
No ☐
Spouse etc.
Yes ☐
No ☐
2 / Stock /Stock Options
Profit from stocksof one single company or organizationwhich exceeds an annual total of 1,000,000 yen, or 5% or more of total shares of one company/organization / Author
Yes ☐
No ☐
Spouse etc
Yes ☐
No ☐
3 / Patent royalties/licensing fees
Patent royalties/licensing fees which exceeds an annual total of1,000,000 yen froma single company or organization / Author
Yes ☐
No ☐
Spouse etc.
Yes ☐
No ☐
4 / Remuneration (e.g. lecture fees)
Remuneration for attending meetings (presentations), paid for the time and effort of the activity, which exceeds an annual total of 500,000 yen,per company or organization / Author
Yes ☐
No ☐
5 / Manuscript fees
Manuscript fees for writing of pamphlets etc. , which exceeds an annual total of 500,000 yen per company or organizationannually from one commercial entity / Author
Yes ☐
No ☐
6 / Research funding
Research funds (trust research funds, joint research funds etc.) provided by a single company or organization which exceeds an annual total of 1,000,000 yen / Author
Yes ☐
No ☐
7 / Scholarship funds or Donations
Scholarship funds granted by a single company or organization which exceeds an annual amount of 1,000,000 yen to the affiliated department or field from one single company or organization / Author
Yes ☐
No ☐
8 / Endowed departments by commercial entities
(If the individuals disclosing COI is affiliated with an endowed department sponsored by a company or organization) / Author
Yes ☐
No ☐
9 / Stock /Stock Options
Profit from stocksof one single company or organizationwhich exceeds an annual total of 1,000,000 yen, or 5% or more of total shares of one company/organization / Author
Yes ☐
No ☐
Copyrights of your abstract: Please check the box below.
☐I agree that organizing committee publishes abstract in terms of copyright belonging to authors.
We cannot issue your abstract without this agreement.

Please fill out all required information and send this form to

Thank you for your abstract submission.

1

The 24th Annual Meeting of the Japanese Association of Cardiac Rehabilitation