[Palliative care in patients without cancer: Impact of the end-of-life care team].

Palliative care improves the quality of life of patients and their families facing problems associated with life-threatening illnesses by promoting the prevention and relief of suffering. Palliative care in Japan has been developed mainly for cancer patients. At the National Center for Geriatrics and Gerontology, an end-of-life care team (EOLCT) has been developed to promote palliative care for patients without cancer. In the first 6 months of its operation, 109 requests were received by the team, 40% of which were for patients without cancer or related disease, including dementia, frailty due to advanced age, chronic respiratory failure, chronic heart failure, and intractable neurologic diseases. The main purpose of the EOLCT is to alleviate suffering. The relevant activities of the team include the use of opioids, providing family care, and giving support in decision-making (advance care planning) regarding withholding; enforcement; and withdrawal of mechanical ventilators, gastric feeding tubes, and artificial alimentation. The EOLCT is also involved in ongoing discussions of ethical problems. The team is actively engaged in the activities of the Japanese Geriatric Society and contributes to the development of decision-making guidelines for end-of-life by the Ministry of Health, Labour and Welfare. The EOLCT can be helpful in promoting palliative care for patients with diseases other than cancer. The team offers support during times of difficulty and decision-making.

[Usefulness of support from end-of-life care teams in difficult decision-making].

It is unclear how hospitals should support a patient's decision to return home to die. Thus, we retrospectively examined the usefulness of support from an End-Of-Life Care Team in such difficult decision making. The subjects included non-cancer patients and the elderly. Our results suggest that the burden of making difficult decisions decreases with support from End- Of-Life Care Teams.

[Comprehensive geriatric assessment and cancer care-choice of treatment and in-home palliative care executed by using advance care planning].

Choice of treatment and in-home palliative care are important for the cancer care of the elderly. In recent years, comprehensive geriatric assessment (CGA), which has been developed as a multidimensional evaluation method for the elderly, has been attracting attention for cancer care as well. CGA can be a common language for the choice of treatment and in-home palliative care of elderly cancer patients. Also, advance care planning (ACP), is important as a process that supports decision making. In the future, better choices of treatment will become available, and in-home palliative care will be improved by carrying out cancer care using CGA, while continuously carrying out ACP as an organization, realizing a high quality of life (QOL) of the elderly.

[Role of home medical care support system in aged cancer patients' symptom relief and regional alliances].

The aim of this study was to evaluate the role of home medical care support system to relieve the symptom and regional alliances for elderly cancer patients. We investigated clinical parameters to study the features of this system. The home medical care support system is designed for patients who are B75-year-old with decrease in activities of daily living and severe dementia. The support system plays a significant role in patients with impaired oral ingestion, dyspnea, delirium, and a poor general status.

[Medical care support intervention to the patient and family who has chosen a terminal care at home - an influence of satisfactory experience on the culture of terminal care].

The National Center for Geriatrics and Gerontology in Japan implemented a home medical care support system for aged patients in April 2009. In this study, we report a case of terminal care system where a medical care intervention was carried out by a close coordination of visiting nurses and other staffs with a "at-home terminal care" brochure on hand, and we discussed how this system was brought forward satisfactory and how it affected this culture.

Screening for methicillin-resistant Staphylococcus aureus (MRSA) carriage on admission to a geriatric hospital.

Our objective is to identify risk factors for carriage of MRSA on admission to a geriatric hospital where MRSA is endemic. A prospective screening for MRSA carriage was conducted by swabbing anterior nares and anal skin for 6 weeks. One hundred and thirty-eight patients aged over 65 were enrolled after obtaining their informed consent. Swabs of anterior nares and anal skin of patients were submitted for culture for MRSA. The demographic, administrative, and clinical data for each participant were recorded, and their association with MRSA carriage was determined by stepwise regression analysis. MRSA was recovered from 11 patients (11/138 patients, 8.0%), and from anal skin in 8 of them. Without screening of anal skin, 5 out of 11 carriers had been missed. Multivariate analysis revealed that hypoalbuminemia (adjusted risk ratio, RR=6.39, 95% confidence interval, CI=1.08-37.84) and bedridden status (RR=8.26, CI=1.04-65.31) were independent risk factors. Screening of elderly patients for gastrointestinal colonization on admission had implications for early detection of the reservoir of MRSA. Systematic selective screening for MRSA carriage targeting high-risk patients with hypoalbuminemia or bedridden status would be useful for infection control of this resistant organism.

SLC11A1 (formerly NRAMP1) polymorphisms associated with multidrug-resistant tuberculosis.

The solute carrier family 11 member 1 gene (SLC11A1, formerly known as NRAMP1: natural resistance-associated macrophage protein 1) is one of the host genetic factors reported to affect susceptibility to tuberculosis. The aim of this study was to determine whether SLC11A1 polymorphisms affect the incidence of multidrug-resistant tuberculosis (MDR-TB) and other clinical features of pulmonary tuberculosis. Using polymerase chain reaction and the restriction fragment-length polymorphism analyses, we investigated four previously reported SLC11A1 polymorphisms, variations in 5'(GT)n, INT4, D543N, and 3'UTR in 95 patients with pulmonary tuberculosis including 10 MDR-TB patients. Clinical information, including elapsed time for sputum culture conversion, extent of pulmonary involvement, and presence or absence of cavitary lesions, was based on a review of charts and chest radiographs. For the 10 MDR-TB patients, previous therapy and treatment compliance were also evaluated. Although the number of MDR-TB patients was small, our preliminary study showed that the variations of D543N and 3'UTR are significantly associated with the incidence of MDR-TB (odds ratio [OR]=5.03, 95% confidence interval [CI]=1.24-20.62; P=0.02), longer time to sputum culture conversion (OR=3.86, 95% CI=1.23-12.23; P=0.02), and cavity formation (OR=5.04, 95% CI=1.51-23.13; P=0.02). Three out of the 10 MDR-TB patients with good treatment compliance had at least one genetic variation in SLC11A1. These data suggested that genetic variations in SLC11A1 may affect the incidence of MDR-TB and clinical features of pulmonary tuberculosis. Further studies are needed to confirm this association with increased number of MDR-TB patients.

Metastasis of the gastrointestinal tract: FDG-PET imaging.

We assess the usefulness of F-18-fluoro-deoxyglucose (FDG) positron emission tomography (PET) in the evaluation of gastrointestinal metastases. Four cases (five lesions) in which metastases from three lung cancers and one malignant fibrous histiocytoma (MFH) of the femur were found in the gastrointestinal tract were reviewed (men/women 3 : 1, age 63-78 years, mean 72 years). The five lesions were duodenal, jejunal metastasis, and two stomach metastases from lung carcinoma, and rectal metastasis from MFH of the femur. FDG-PET was unable to detect small masses, but it was able to detect unforeseen lesions such as gastrointestinal metastases because FDG-PET is a whole-body scan in a single-operation examination. FDG-PET imaging provided valuable information for the diagnosis of gastrointestinal metastasis.

[Nosocomial infection of scabies in national hospitals and sanatoria in Japan].

The aim of this study was to investigate cases of nosocomial infection of scabies in the national hospitals in Japan. Questionnaires sent to 183 hospitals and sanatoria were returned by 93. Fifty-three cases in 24 institutions of nosocomial infection were reported in the past 5 years. No nosocomial infection was reported from 7 sanatoria for Hansen's diseases where the patients were relatively older and had higher ADL scores. It took 7.5 weeks on the average to eliminate nosocomial infection and more than 8 weeks were required to control them in the hospitals where more than 10 cases had occurred. Benzyl benzoate, gamma benzene hexachloride, and Pyrethroids, which were not approved as drugs for the treatment of scabies in Japan, were used in the all institutions where nosocomial infection occurred except for one institution. Problems to be solved were as follows; (1) delay of diagnosis and treatment, (2) lack of nursing staff, (3) difficulties of complete isolation due to lack of spaces, inability of patients to understand the need for isolation and also the psychological instability of the isolated patients, (4) recurrence due to the use of ineffective drugs, (5) insufficient information about the prevalence of scabies in the previous institutions, (6) misdiagnosis of non-scabies patients with itchy skin rash as the scabies, (7) inconsisitent care due to poor evaluation of skin lesions.

Evaluation of a commercially available serologic assay for antibodies against tuberculosis-associated glycolipid antigen.

A commercially available enzyme immunoassay developed to detect antibodies to a tuberculosis-associated glycolipid antigen was evaluated for serologic diagnosis of tuberculosis. This was a multicenter study comparing the assay with other methods in 78 patients with active pulmonary tuberculosis and in 54 controls with non-tuberculous lung diseases. Sensitivities were highest for sputum culture (91.0%), followed by immunoassay (79.5%), nucleic acid amplification (77.3%), and finally acid-fast staining of sputum smear (60.3%). Immunoassay and amplification, both rapid methods, had similarly high sensitivity in smear-positive subjects (89.4 and 88.9%, respectively); in smear-negative subjects these two techniques showed low sensitivity (64.5 and 60.0%, respectively). Concordance between the two methods was relatively low (72.0%). With regard to specificity, seven out of ten patients with old tuberculosis had positive result by immunoassay (30% specificity). In the control group, 10 out of 54 patients had positive immunoassay result (72.2% specificity), with notably limited specificity in the elderly. The tuberculous glycolipid assay is a rapid method sufficiently sensitive for detection of tuberculosis infection, even in smear-negative patients.