Palliative Care and End-of-Life Care in the Community What Can We Focus on? / 日本農村医学会雑誌

The goal of palliative care is to soothe or relieve the patients with serious illness of their suffering and to improve the quality of their life. It integrates the physical, psychological, social and spiritual aspects of patient care into a comprehensive whole. Doctors and other medical workers talk with the patients by providing appropriate information and explanations and care should be carried out according to the patients' wishes. The care team should confirm their wishes at every opportunity since the patients' wishes can change with time. The presenters who were actually involved in medical care or nursing care discussed how to solve the problems of palliative care and end-of-life care.

Optimal Serum 25-Hydroxyvitamin D3 Level Associated with Functional Capacity and Physical Function among Frail Elderly People Living in Rural Area / 日本農村医学会雑誌

The purpose of this study was to investigate an optimal 25-hydroxyvitamin D3 [25(OH)D] level for Japanese frail elderly people aged 65 and above from the standpoint of quality of life, functional capacity, and physical function. A longitudinal study was conducted in two towns (latitude 36 degrees north) from 2006 to 2008. The subjects were 125 frail elderly individuals living in a rural setting and attending a 3-month exercise class for prevention of age-related diseases in order that they could do without receiving nursing care. An interview was conducted based on a questionnaire, and blood data, and physical fitness tests were administered to them at baseline and at the end of the 3-month exercise class. Functional capacity and physical fitness were compared on the basis of 25(OH)D≥50 nmol/L as a usual cut-off point, and 25(OH)D≥75 nmol/L as a severer cut-off point. A comparison of changes in physical fitness between before and after exercise class was done. The mean 25(OH)D level (±SD) was 58.9±13.6 nmol/L at baseline. The ratios of 25(OH)D level less than 50.0 nmol/L and less than 75.0 nmol/L were 23.9%, and 87.2%, respectively. The rates of house-bound subjects and those with worse scores of QOL were significantly higher in the group with 25(OH)D<50.0 nmol/L compared with the group with 25(OH)D≥50 nmol/L. The rate of those with superior functional capacity was significantly higher in the group with 25(OH)D≥75 nmol/L than the group with 25(OH)D<75 nmol/L. At the end of the 3-month exercise, Timed Up & Go indicating walking ability improved significantly in the group with 25(OH)D≥50 nmol/L, and an alternate step test indicating lower extremity strength significantly improved in the group with 25(OH)D≥75 nmol/L. From these findings, it was suggested that 25(OH)D level more than 50 nmol/L would be needed to maintain walking ability of the Japanese frail elderly and that 25(OH)D level more than 75 nmol/L would be needed to maintain lower extremity strength or functional capacity.

Burdens to Family Members in Home Care and Related QOL Factors / 日本農村医学会雑誌

This study was conducted to shed light on the actual conditions of home care and quality-of-life factors related to the burdens on families. For this purpose, a survey was carried out on main caretakers in the families who were using our home care support service. Fundamental information about the main caretakers and those who need care were garnered. In addition, WHO/QOL-26 and burdens for main caretakers were checked up on.The survey found that those who have looked after the sick or invalid for less than six months and those over five years keenly felt that they were shouldering a heavy burden. With the progression of dementia, the caretakers increasingly felt the burden getting heavier. Physical factors in QOL were linked to the burden which caretakers feel has to be borne, but psychological and social factors were not. This finding might have been ascribed to the fact that the persons surveyed were residents of the provincial city, part of which is rural. They were mostly old women and must have gained the support of their relatives. It is easy to assume that their role perception and sense of responsibility together with regional characteristics were reflected in psychological and social QOL factors.

Cognitive Impairment and Nocturnal Blood Pressure Fall in Treated Elderly Hypertensives

Objectives: We investigated the association between the fall of nocturnal blood pressure (BP) and cognitive impairment in elderly subjects. Methods: The study was a cross-sectional survey of 204 elderly subjects who had no cerebrovasucular episodes. Ambulatory BP monitoring and assessments of cognitive functions using the Mini-Mental State Examination (MMSE) were performed at the subjects' homes. We classified the subjects treated with antihypertensive drugs into three groups: non-dippers (nocturnal fall <10% of the mean day diastolic BP; n=51), normal dippers (10% to less than 20%; n=58), and extreme dippers (20% or more; n=17). The subjects not treated with antihypertensive drugs were also classified as non-dippers (n=40), normal dippers (n=24), and extreme dippers (n=14). Results: The mean age of participants was 75.2±7.2 years, and 126 (61.7%) were being treated with antihypertensive drugs. In the group of antihypertensive drug users, the number with MMSE£23 was 30 and the adjusted odds ratio for cognitive impairment in those with an extreme dip in diastolic BP (DBP) was 4.18 (95% CI, 1.07−16.40) in reference to the normal dippers. In contrast, no association was observed between cognitive function and nocturnal BP fall in the group no using antihypertensive drugs. Conclusions: Cognitive impairment was associated with an extreme dip in DBP in the antihypertensive drug users only. It remains to be seen whether careful monitoring of nighttime BP as well as daytime BP may reduce the risk of cognitive impairment in antihypertensive drug users.

The Education Effects of an Early Exposure Program for Medical Students at University of Tsukuba: Analysis of Setting and Satisfaction with the Program / 医学教育

In 1996 we started an early exposure program of nursing and care for medical school freshmen at University of Tsukuba. The program consisted of out-of-hospital practice and in-hospital practice; 195 medical students completed the program in the 1999-2000 academic year. We analyzed students' questionnaires about satisfaction with the program after each practice and studied better settings for early exposure. Students were randomized to three out-ofhospital settings (nursing home, facilities for the elderly, and home-visit nursing) and also randomized the order of the practice (in-hospital or out-of-hospital first). The mean satisfaction score for setting was the highest for the home-visit nursing and lowest for nursing homes. The mean satisfaction score for order of practice was higher when in-hospital practice was done first.

Treated hypertensives with good medication compliance are still in a state of uncontrolled blood pressure in the Japanese elderly

<p><b>OBJECTIVES</b>Blood pressure (BP) is poorly controlled in many countries. Poor compliance was suggested as the main cause for poor BP control. The purpose of this study was to examine the association between compliance and the control of both casual blood pressure (BP) and 24-hr ambulatory BP in a Japanese elderly population.</p><p><b>METHODS</b>The study was a cross-sectional survey. Casual BP and 24-hr ambulatory BP were measured at home. Hypertension was defined as casual systolic BP (SBP)≧140 and/or diastolic BP (DBP)≧90 mmHg, or as treated hypertension. A compliance rate of greater than 80% by the pill count method was defined as good compliance.</p><p><b>RESULTS</b>Of the 178 treated hypertensives, 82.6% showed good compliance. Between the treated hypertensives with good compliance and those with poor compliance, no significant difference was found in either casual BP or ambulatory BP. Of the treated hypertensives with good compliance, the prevalence of achieved target ambulatory BP, i.e., daytime BP<135/85 mmHg, nighttime BP<120/75 mmHg, and 24-hr BP<125/80 mmHg, was, respectively, 35.4%, 43.5%, and 20.4%.</p><p><b>CONCLUSIONS</b>Casual BP and 24-hr ambulatory BP were poorly controlled in the community-living elderly although many of the treated hypertensives showed good compliance. It is unlikely that this inadequate control of hypertension is due to poor compliance on the part of the subjects.</p>

Treated Hypertensives with Good Medication Compliance are Still in a State of Uncontrolled Blood Pressure in the Japanese Elderly

Objectives: Blood pressure (BP) is poorly controlled in many countries. Poor compliance was suggested as the main cause for poor BP control. The purpose of this study was to examine the association between compliance and the control of both casual blood pressure (BP) and 24-hr ambulatory BP in a Japanese elderly population. Methods: The study was a cross-sectional survey. Casual BP and 24-hr ambulatory BP were measured at home. Hypertension was defined as casual systolic BP (SBP)³140 and/or diastolic BP (DBP)³90 mmHg, or as treated hypertension. A compliance rate of greater than 80% by the pill count method was defined as good compliance. Results: Of the 178 treated hypertensives, 82.6% showed good compliance. Between the treated hypertensives with good compliance and those with poor compliance, no significant difference was found in either casual BP or ambulatory BP. Of the treated hypertensives with good compliance, the prevalence of achieved target ambulatory BP, i.e., daytime BP<135/85 mmHg, nighttime BP<120/75 mmHg, and 24-hr BP<125/80 mmHg, was, respectively, 35.4%, 43.5%, and 20.4%. Conclusions: Casual BP and 24-hr ambulatory BP were poorly controlled in the community-living elderly although many of the treated hypertensives showed good compliance. It is unlikely that this inadequate control of hypertension is due to poor compliance on the part of the subjects.

A Study of the Significance and Problems of Learning About Nursing in Medical Education from Nurses' Point of View / 医学教育

Although attempts to teach medical students about nursing have become more frequent, nurses who have lectured to medical students and have been involved in their practical training have rarely published studies evaluating their training methods and objectives. This study was performed to clarify the significance and problems of such teaching. Nurses now participate in the education and training of medical students in at least half of medical training hospitals and schools. They thought that this is a unique and beneficial educational opportunity and had high expectations. However, four main problems have been identified: the motivation and attitudes of medical students, the time and environment for training, the understanding of clinicians, and the problems of nurses, such as lack of educational experience.

Genetic and Environmental Factors Affecting Peak Bone Mass in Premenopausal Japanese Women

The purpose of this study was to examine the relationships between peak bone mass and genetic and environmental factors. We measured whole-body bone mineral density (BMD), lumbar spine BMD, and radius BMD with dual-energy X-ray absorptiometry (DXA) and analyzed eight genetic factors: vitamin D receptor (VDR)-3', VDR-5', estrogen receptor (ER), calcitonin receptor (CTR), parathyroid hormone (PTH), osteocalcin (OC), apolipoprotein E (ApoE), and fatty acid binding protein 2 (FABP2) allelic polymorphisms using polymerase chain reaction-restriction fragment length polymorphisms (PCR-RFLPs). We also surveyed menstrual history, food intake, and history of physical activity using questionnaires. After adjusting for age, body mass index (BMI), current smoking status, current Ca intake, alcohol intake, menoxenia, and physical activity, the mean BMD in subjects with the HH/Hh genotype was significantly higher than that of subjects with the hh genotype for whole-body BMD (mean±SD, 1.20±0.10 vs. 1.18 ±0.09 g/cm2; HH/Hh vs. hh, p=0.04) and at lumbar spine BMD (mean±SD, 1.18±0.14 vs. 1.14±0.12 g/cm2; HH/Hh vs. hh, p=0.02) in OC allelic polymorphism. Furthermore, the results of multiple regression analyses taking the 8 genetic factors plus the 7 environmental factors listed above into account showed that the strongest factor contributing to BMD was BMI at any site (whole-body and lumbar BMD p<0.0001, radius BMD p=0.0029). In addition, OC polymorphism (p=0.0099), physical activity (p=0.0245), menoxenia (p=0.0384), and PTH polymorphism (p=0.0425) were independent determinants for whole-body BMD, and OC polymorphism (p=0.0137) and physical activity (p=0.0421) were independent determinants for lumbar BMD and radius BMD, respectively.

Occlusal Function Associated with Body Composition in Premenopausal Japanese Women

Objectives: The goal of the present study was to investigate the relationship between occlusal function and body composition in 108 premenopausal healthy Japanese women aged 20−45 years. Methods: Pressure-sensitive sheets were used to measure occlusal function. Whole fat mass and lean mass, fat-free mass, and whole-bone mineral content were measured by dual-energy X-ray absorptiometry (DXA). Results: After being adjusted for age and the square of height, the whole lean mass and grip strength of the large occlusal contact-area group were found to be significantly higher than those of the small occlusal area groups (p<0.05, respectively). In the 1-year follow-up study, changes in weight in the small-occlusal contact-area group and the low-occlusal force group were significantly larger than other occlusal-contact area or occlusal-force groups. The mean occlusal-contact area and occlusal force were both significantly smaller in subjects with partial dentures than in those without (p<0.05). Conclusion: Large occlusal contact-area, high occlusal force, and no dentures may be associated with some good health conditions in premenopausal Japanese women.

Pre-End-Stage Renal Disease(Pre-ESRD) Care in the U.S.A / 日本農村医学会雑誌

A significant delay in identifying pre-ESRD patients is not infrequent in the U.S.A. because an early examination for proteinuria is not common, and renal disease is infrequently documented even when proteinuria and/or an elevated serum creatinine level have existed. Although there are accepted strategies for slowing the progression of renal disease such as the use of an angiotensin converting enzyme (ACE) inhibitor in diabetic patients or suboptimal blood pressure control in hypertensive patients, these strategies are seldom employed. It is also particularly alarming that the patients are often low in the overall health status, hypoalbumic, or anemic at dialysis initiation, and begin dialysis without permanent vascular access or without any education regarding dialysis therapy in many instances.

Housing Projects for Comfortable and Independent Life of Aged People. A Report Concerning Housing with Services for Aged People / 日本農村医学会雑誌

In Japan, the number of people 65 and over is increasing while the number of children is decreasing. A greater number of senior citizens live by themselves or husband and wife alone than before.<BR>To realize comfortable and independent life for aged people, it is important to prepare housing and environment which have special services for them.<BR>We would like to explain two housing projects which were planned and are being put into execution in Japan. One is ‘Silver Housing’ multiunit dwellings for the aged built by the Ministry of Construction and the Ministry of Health and Welfare since 1987. The other is ‘Silver Peer’ project which has been pushed forward by the Tokyo Metropolitan Government since 1987.

A Study on the Education Effects of Medical Team Care Practice at the University of Tsukuba: Analysis of Reports on the Practice / 医学教育

The need for medical team care is increasing because of advances in medical care and changing national needs. For more than 20 years medical students at the University of Tsukuba have participated in medical team care practice before bedside learning during the third trimester of their 4th year. The objective of this practice is to understand patients from the nurses' point of view and to learn cooperation between doctors and co-medical staff. We analyzed students reports to study what they had learned. A total of 326 items in 11 categories were specified in the free-response part of the reports. The largest category was “nursing/nurses” and the second largest was “communication/human relations.” The results show that the students learned points other than the General Instruction Objectives and that the practice was extremely effective.

Determination of Bone Mass for Diagnosis of Osteoporosis: Comparison of Computed X-Ray Densitometry(CXD) with Quantitative Computed Tomography(QCT) / 日本農村医学会雑誌

Measurement of bone mass (BM), especially in the lumbar vertebrae, is very important for diagnosis of osteoporosis. In this study, we compared BM values measured by computed X-ray densitometry (CXD) with those by quantitative computed tomography (QCT), and discussed differences between the two methods.<BR>The subjects were 90 women and 3 men, aged 42-86 years, who visited our outpatient department of osteoporosis. Metacarpal bone density (ΣGS/D) and metacarpal index (MCI) in the second metacarpal bone were measured by CXD. QCT was uesd for measurement of bone mineral density (BMD) in the lumbar trabecular bone, where pronounced osteoporotic changes occur early. The mineral values of L3 were expressed as mineral equivalent of CaCO<SUP>3</SUP> in mg/ cm<SUP>3</SUP>, and≤75 mg/cm<SUP>3</SUP> of L3 values were judged to be loss of lumbar BMD.<BR>There were negative correlations between age and ΣGS/D, MCI or L3 value, and positive correlations were found between ΣGS/D or MCI and L3 value. Based on the above criterion of lumbar BMD loss, sensitivity and specificity of ΣGS/D for lumbar bone loss were examined. If ΣGS /D of 2.30 (T score -2.7) was used as the cut-off point, the sensitivity was 69.8% and the specificity was 75.0%, and if ΣGS/D of 2.37 (T score -2.3) and 2.40 (T score -2.1) were employed, the sensitivity was 79.1% and 79.1%, while the specificity was 64.5% and 62.5%, respectively. We concluded that BM values of cortical bone and trabecular bone decrease with age, and that sensitivity and specificity of GS/D for diagnosis of lumbar BMD loss are not very high.

Bone Mineral Density in Women in Its Relationships with Dietary Habits, Especially in Their Youth, and Physiologic Factors / 日本農村医学会雑誌

We assessed the relationships between lumbar bone mineral density (BMD) in middle and old-aged women and dietary habits, especially in their youth (about 18-25 years) and physiologic factors (height, weight, menarche, menopause, etc.). The subjects were 90 women at age 45-87 [63.5±9.5 (mean±SD) years] who visited our outpatient clinic of osteoporosis. Of them, 83 women had already ceased menstruation. Quantitave computed tomography (QCT) was used for measurements of the BMD of the trabecular bone in the third lumber vertebra (L3 expressed in mg/cm<SUP>3</SUP> of CaCO<SUB>3</SUB>), where pronounced changes associated with osteoporosis occur early.<BR>There were significant negative correlations between age or menarcheal age and BMD of L3. Significant positive correlations were found between height or weight at the present and L3, but there was no correlation between body mass index (BMI) and L3. Significant positive correlations were noted between the values subtracted height at the present from height in the youth and L3. There were no correlations between frequency of pregnancy and delivery or outdoor life hour and L3. High milk-consumers in their youth (milk-drinking≥5 days per week) had higher L3 than low milk-consumers (milk-drinking≤2 days per week), and women, who had ate small fish 3 days or more per week in their youth, showed significantly higher L3 than thoes who had 2 days or less per week. We concluded that there are negative correlations between age or menarcheal age and L3 and positive correlations between height or weight and L3, and that low intake of milk and small fish in the youth may influence BMD in later years, leading to osteoporosis.