[Analysis of Delirium in Patients with Malignant Tumor in Palliative Care Unit].

BACKGROUND: Since delirium has various adverse effects in patients with malignant tumors, it is important to eliminate the cause. We investigated delirium in patients with malignant tumors. METHOD: Seventy seven malignant tumor patients who admitted to palliative care unit from May 2015 to March 2016 were subjected to a retrospective analysis of delirium. RESULTS: Delirium was present in 17 patients(22.1%)on admission, and in 38 patients(49.4%)before discharge. After hospitalization, delirium improved without relapse in 5 patients(29%)and the onset of delirium was avoided in 34 patients(57%). Factors of delirium at admission were nausea and day/night reversal, factors of delirium at discharge were dementia, pain, and day/night reversal. CONCLUSIONS: In the present study, we investigated the causes and course of delirium in patients with malignant tumors.

[Analysis of Early Palliative Care for Patients with Gastric Cancer].

BACKGROUND: Palliative care delivered to cancer patients late in the course of disease are inadequate to improve advance care planning and quality of life; thus, early palliative care is recommended. We retrospectively analyzed early palliative care delivered to patients with gastric cancer. METHOD: Forty-nine gastric cancer patients who underwent surgery and had received interdisciplinary care from the first visit(early palliative care)were assessed for physical and psychosocial symptoms. RESULTS: All patients were followed up continuously by a nurse certified in palliative care support to provide quality patient-centered care from the beginning(advance care planning). Four patients had experienced relapse, and 3 older patients had decided not to receive chemotherapy following their advance care planning. However, all 4 patients were admitted to a palliative care unit without barriers. CONCLUSION: Early palliative care might lead patients to have advance care planning, and a better quality of life.

Association between Passive Smoking from the Mother and Pediatric Crohn's Disease: A Japanese Multicenter Study.

Smoking is a risk factor for adult-onset Crohn's disease (CD). Although passive smoking from family members is a major concern, especially in pediatric CD, the number of existing epidemiological studies is limited. This multicenter case-control study aimed to assess the effects of familial smoking on pediatric CD. We examined 22 pediatric CD cases and 135 controls. The subjects' mothers were given a self-administered questionnaire about family smoking before disease onset in the CD group or the corresponding period in the control group. Univariable logistic regression model was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), whereas dose-response relationship analyses were performed for more in-depth evaluations. Univariable analyses indicated that passive smoking from the mother (OR, 2.09; 95% CI, 0.61-7.10) was not a significant, but a candidate risk factor for developing pediatric CD. In contrast, the dose-response relationship analyses revealed that passive smoking from the mother (OR, 1.17; 95% CI, 1.04-1.31) was significantly associated with pediatric CD. Therefore, passive smoking from the mother may be predominantly associated with the development of pediatric CD. Further follow-up studies comprising environmental measurements of passive smoking exposure doses and genetic factors interaction analysis are necessary.

[Discharge Dynamics and Related Factors of Long-stay Patients in Psychiatric Hospitals].

A longstanding challenge in Japan is prolonged psychiatric hospitalization and the associated difficulty of discharge, lost opportunities for patients' social participation, and stagnant reallocation of medical resources. Although the length of stay has been shortened recently on average, its distribution tends to be polarized into high-turnover and long-stay groups. To resolve these problems, we must understand the discharge dynamics of long-stay patients. Three questionnaires were sent to 733 randomly selected psychiatric hospitals (response rate: 24.3%; 178 hospitals, 2,480 patients). One questionnaire was on hospitalized patient numbers for one-year or longer stays as at the end of June 2007, recording each combination of Group (A or B), diagnosis, and hospitalization type. Group A referred to patients continuously hospitalized as at the end of June 2008; Group B referred to those discharged between July 2007 and June 2008. The second questionnaire was on hospital characteristics (founder, bed number, medical function, etc.), and the third questionnaire was on detailed patient characteristics (residential setting post-discharge, etc., for each Group B patient; a maximum of 20 patients per hospital consecutively in order of discharge). Valid data were obtained from 171 hospitals and 2,419 patients, with the latter increasing to 3,543 after weighting. The annual discharge rate (ADR; B/[A+B]) for the entire sample was 16.3%. Regarding the diagnosis, dementia showed the highest ADR (27.8%) and schizophrenia the lowest (13.5%). The ADRs for depression, bipolar disorder, and alcoholism were 23.9, 20.6, and 23.7% respectively. Regarding the hospitalization type, voluntary hospitalization (16.0%) and hospitalization for medical care and protection (16.8%) showed similar ADRs. Regarding the district, ADRs were high in Kinki (19.9%) and Kyushu (18.8%), and low in Kanto (14.1%) and Chugoku/Shikoku (14.2%). Multivariate analyses revealed that discharge within one year was significantly correlated with the diagnosis, district, hospital founder, and presence of psychiatric emergency or acute-phase treatment (acute-phase-type) wards in hospitals, but not with the hospitalization type, presence of psychiatric long-term care wards, or presence of senile dementia wards. The probability of discharge (odds ratio [95% confidence interval]) regarding the diagnosis was higher in dementia (2.47 [2.23-2.74]), alcoholism (2.09 [1.71-2.55]), depression (2.07 [1.65-2.59]), and bipolar disorder (1.70 [1.35-2.16]) than in schizophrenia (reference). Regarding the district, the probability was higher in Kinki (1.32 [1.12-1.54]) and Kyushu (1.27 [1.14-1.42]) than Kanto (reference). The probability was also lower in private hospitals (0.58 [0.51-0.66]) than in public/university hospitals (reference), and higher in hospitals with acute-phase-type wards (1.24 [1.14-1.35]) than in those without them (reference). The most common residential setting post-discharge for the total sample of weighted Group B patients was temporary hospitalization in another department prearranging psychiatric readmission (THAD, 35.8%), followed by death (18.2%), living with families/relatives (LF/R, 11.3%), a residential care facility for the aged (RCF-A, 9.5%), residential care facility for the disabled (RCF-D, 8.6%), hospitalization in another psychiatric hospital (7.4%), living alone (LA, 4.3%), permanent hospitalization in another department (PHAD, 4.3%), and others (0.7%). In dementia, death was common (31.0%) ; LF/R (1.8%) and LA (0.0%) were rare. As the age increased, the proportions of LF/R, LA, RCF-D, RCF-A, PHAD, and death changed; particularly, LA decreased and death increased markedly with age. Additionally, THAD amounted to approximately 40% in every age class of 40 years or older, contrasting with 11.4% in those under 40 years. The study's limitations include a low response rate, the elapsed time after the survey, and lack of attention paid to symptom severity. Nevertheless, it provides valuable insights into long-stay patients, including that discharge is least likely in schizophrenia and most likely via transfer or death for dementia. These results may encourage the efficient promotion of discharge and prevention of prolonged hospitalization according to patients' demographic, clinical, and social conditions.

[Assessment of validity of the archived standard curve in endotoxin assay, produced in other facilities].

We have reported the possibility of the use of the archived standard curve of endotoxin assay, which is prepared in the same facility from the viewpoint of the accuracy and precision. In this study, the possibility of the use of the archived standard curves prepared in the different facilities was investigated with the same data set in the previous paper. The evaluation was performed with the recovery rate of the concentrations of the standard solutions, as the same method as the previous study. The clotting times of the standard solutions were substituted into the standard curves prepared in the different facilities from those, in which standard solutions were prepared. The recovery rates were 86.1-125.0%, and the range was almost the same as that when the facility preparing standard solutions were the same as that preparing the standard curve. From this data, if the protocols of the preparation of standard solutions, such as mixing and the interval timing until set to the apparatus and so on, can be set the same between the endotoxin test and the preparation of the archived standard curves, the endotoxin concentration calculated with the archived standard curves prepared in other facilities were not varied very much, compared to the true values and the values obtained from the use of the archived standard curves prepared in the same facility.

The fatty acid profile of the erythrocyte membrane in initial-onset inflammatory bowel disease patients.

BACKGROUND AND OBJECTIVES: The sudden change in the dietary habits of the Japanese population towards a European/American-style diet since the 1960s is thought to be responsible for the recent increase in the incidence of inflammatory bowel disease (IBD) in Japan. Dietary fatty acid intake influences the fatty acid profiles of vital cell membranes, which might be a source of inflammatory mediators. METHODS: We investigated the fatty acid composition of the erythrocyte membrane in 90 healthy Japanese and 43 initial-onset IBD patients (ulcerative colitis, UC: 25; Crohn's disease, CD: 18) who had not undergone any dietary intervention to examine the role fatty acids play in the onset of IBD. RESULTS: The erythrocyte membrane n-3/n-6 ratio of the initial-onset IBD patients was 0.42 ± 0.13, which was not significantly different from that of the healthy Japanese subjects (0.41 ± 0.13). However, the CD patients displayed a significantly lower mean percentage weight (MPW) of linoleic acid (LA) than the healthy subjects (8.25 ± 1.75 vs. 9.90 ± 1.29; p < 0.001), while their MPW of arachidonic acid (AA) was significantly higher than those of the healthy subjects and UC patients (11.22 ± 2.18 vs. 9.76 ± 1.64, p < 0.01; vs. 9.58 ± 1.97, p < 0.01, respectively). The mean delta 6-desaturation index of the CD patients was significantly higher than that of the healthy subjects (1.61 ± 0.65 vs. 1.11 ± 0.26; p < 0.001). CONCLUSIONS: The CD patients displayed significantly higher and lower MPW of AA and LA, respectively, than the healthy subjects, suggesting that delta 6-desaturase is hyperactivated in CD. The cell membrane fatty acid profile might be a therapeutic target in CD.

[Assessment of validity of the archived standard curve in endotoxin assay].

The archived standard curve of endotoxin assay was evaluated to be possible to be used for the endotoxin assay as the reliable standard curve, instead the standard curve was produced each time of the assay. The archived standard curve shall be produced from three standard curves for three days, following the guidance issued from FDA in 1991, and the evaluation whether the archived standard curves can be applicable to use daily was performed with the recovery rate of the concentrations obtained from the archived standard curves against the true values. The three case studies were prepared: (1) the same person, who prepared the archived standard curves, performed this assay with the standard solutions (repeatability condition with the same tester, at the same facility), (2) the person, who did not prepare the archived standard curves, performed this assay with standard solutions (reproducibility condition with the different tester and dates), (3) the same preparation as (1), but using different three lots of lysates. The recovery rates were (1) 85-127%, (2) 86-124%, (3) 64-156%, respectively. From this data, the endotoxin concentration calculated with the archived standard curves were not varied very much, compared to the true values, but further discussion are necessary when the archived standard curves would be applied in daily analysis of PET drugs, regarding the protocol, the requirement to use the archived standard curve and the daily internal control as system suitability tests.

[Discharge dynamics and related factors of newly-admitted patients in psychiatric hospitals].

The focus of psychiatric services in Japan is being shifted from hospitalization to community care, and the Ministry of Health, Labour and Welfare aims for the prompt discharge of newly-admitted patients. Correspondingly, it set a goal to lower the "mean residual rate (MRR)", which indicates the discharge dynamics of newly-admitted patients, to 24%. As a measure to achieve this goal, the present situation should be investigated in each homogeneous patient group. In this study, we conducted a survey of newly-admitted patients to investigate discharge dynamics and related factors by the diagnosis and type of hospitalization. Out of 1,459 psychiatric hospitals to which we sent questionnaires, 183 (12.5%) replied. Each hospital completed questionnaires regarding a maximum of 5 patients for each type of hospitalization (voluntary hospitalization [VH], hospitalization for medical care and protection [HMCP], and involuntary hospitalization ordered by the prefectural governor [IHOPG]) between October 2005 and January 2006. We weighted the obtained patient data in proportion to the estimated total number of patients, and analyzed valid data on 1,784 patients. The MRR for the whole sample was 29.4%. By diagnosis, dementia showed the highest MRR (45.6%), followed by schizophrenia (34.9%); depression, bipolar disorder, and alcoholism showed the lowest MRRs (20-21%). We calculated MRRs by the type of hospitalization for dementia and the other diagnoses separately, considering confounding effect between the diagnosis and type of hospitalization (markedly high proportion of HMCP observed in dementia). In dementia, HMCP showed a higher MRR (46.8%) than VH (43.7%). In the other diagnoses, IHOPG showed the highest MRR (43.7%), followed by HMCP (34.5%) and VH (25.6%). Dementia differed from the other diagnoses in the distribution of residential settings before admission, with a higher proportion of residential care facilities (25.5%) and hospitalization in other departments (19.3%). In dementia, the residential setting after discharge showed a similar distribution, and death was also frequent (6.6%). Multivariate analyses revealed that a long stay (one year or longer) was significantly associated with a residential setting before admission, the type of ward at admission, a founder (a private hospital or public/university hospital), and symptom severity at admission in schizophrenia; and with the type of ward at admission and hospital founder in dementia. In schizophrenia, the risk of a long stay was higher on hospitalization in other psychiatric hospitals (odds ratio [OR] : 28) and other departments (OR: 18), and living alone (OR: 2.1) than in living with the family by residential setting. The risk was also higher in psychiatric long-term care wards than in general psychiatric wards by the type of ward (OR: 3.0), and in private hospitals than in public/university hospitals by hospital founder (OR: 3.0). Additionally, the higher risk was associated with higher symptom severity assessed using a 6-point scale (OR: 1.3 per point). In dementia, the risk was higher in senile dementia wards than in general psychiatric wards by the type of ward (OR: 2.9), and in private hospitals than in public/university hospitals by hospital founder (OR: 6.8). The most frequently reported direct causes of a long stay were problems regarding a family's acceptance (51.5%), poor improvement of symptoms (48.8%), and poor recovery of daily living abilities (44.0%). In dementia, physical diseases (20.8%) and undecidedness of residence after discharge (29.2%) were also frequent. Considering the elapsed time after survey, the low response rate, and the data analyses with sampling bias adjustment, the results should be interpreted carefully. Nevertheless, the discharge dynamics and related factors in newly-admitted patients varied with the diagnosis and type of hospitalization. Particularly, schizophrenia and dementia, as well as IHOPG and HMCP, showed high MRRs and frequent long stays. Additionally, a long stay was related to patients' demographic and social characteristics. Adopting measures suiting patients' characteristics and arranging treatment and casework for patients at high risk of a long stay are important to facilitate community care.

N-3 polyunsaturated fatty acid diet therapy for patients with inflammatory bowel disease.

BACKGROUND: N-3 polyunsaturated fatty acids (PUFA) are considered important pharmaconutrients for modulating mucosal immunity and therapeutic responses in patients with inflammatory bowel disease (IBD). We investigated the influence of diet therapy involving the use of an "n-3 PUFA food exchange table" (n-3DP) on the fatty acid composition of the erythrocyte membranes of IBD patients and its remission-maintaining effects. METHODS: We analyzed the fatty acid composition of the erythrocyte membrane before and after n-3DP intervention in 20 initial-onset IBD patients who had not undergone any dietary intervention. We then analyzed it again and evaluated disease activity after 12-18 months intervention in 230 IBD patients (168 ulcerative colitis, 62 Crohn's disease; follow-up group) in whom n-3DP was introduced after remission had been achieved. The follow-up group was divided into remission and relapse groups. RESULTS: In the 20 initial-onset patients, the mean n-3/n-6 ratio significantly increased after intervention (0.41 ± 0.16 versus 0.70 ± 0.20; P < 0.001). In the follow-up group the ratio in the remission group (n = 145) was significantly higher than that in the relapse group (n = 85) (0.65 ± 0.28 versus 0.53 ± 0.18; P < 0.001). The ratio significantly decreased in those who suffered a relapse after the beginning of treatment (P < 0.01). CONCLUSIONS: N-3DP significantly increased the erythrocyte membrane n-3/n-6 ratio in IBD patients, and this ratio was significantly higher in the remission group, suggesting that n-3DP alters the fatty acid composition of the cell membrane and influences clinical activity in IBD patients.

Understanding treatment attitudes toward dementia: differences among community residents and health care professionals.

To examine how the severity of dementia affects attitudes to treatment preferences in a lay group of community residents and a group of medical care professionals who provide direct care to dementia affected patients. The participants were 259 community residents aged between 40 and 65, and 217 care professionals working at nursing homes or group homes. Respondents were randomly assigned to one of two scenarios involving moderate or severe dementia and each was asked questions about their preferences and attitudes to the employment of eight types of active treatments (ATs) to deal with a newly acquired illness as well as eight types of life-sustaining treatment (LST). Among the community residents, there were no significant differences in preferences toward any treatment items between the moderate dementia and severe dementia scenarios. Similarly, care professionals showed no significant differences in attitudes toward 15 of the 16 treatment items. The community residents had more negative attitudes than care professionals in attitudes to all types of LST, including four variations of AT that have a good chance of success. After dementia deprives an individual of decision-making capacity, progress of the disease has little effect on both community residents and care professionals' preferences. When discussing about end-of-life decision-making, care professionals need to be careful about the gaps in perception of good chance treatments with patients.

Survey of the general public's attitudes toward advance directives in Japan: how to respect patients' preferences.

BACKGROUND: Japanese people have become increasingly interested in the expression and enhancement of their individual autonomy in medical decisions made regarding medical treatment at and toward the end of life. However, while many Western countries have implemented legislation that deals with patient autonomy in the case of terminal illness, no such legislation exists in Japan. The rationale for this research is based on the need to investigate patient's preferences regarding treatment at the end of life in order to re-evaluate advance directives policy and practice. METHODS: We conducted a cross-sectional survey with 418 members of the general middle-aged and senior adults (aged between 40 and 65) in Tokyo, Japan. Respondents were asked about their attitudes toward advance directives, and preferences toward treatment options. RESULTS: Over 60% of respondents agreed that it is better to express their wishes regarding advance directives (treatment preferences in writing, appointment of proxy for care decision making, appointment of legal administrator of property, stating preferences regarding disposal of one's property and funeral arrangements) but less than 10% of them had already done so. About 60% of respondents in this study preferred to indicate treatment preferences in broad rather than concrete terms. Over 80% would like to decide treatment preferences in consultation with others (22.2% with their proxy, 11.0% with the doctor, and 47.8% with both their proxy and the doctor). CONCLUSION: This study revealed that many Japanese people indicate an interest in undertaking advance directives. This study found that there is a range of preferences regarding how advance directives are undertaken, thus it is important to recognize that any processes put into place should allow flexibility in order to best respect patients' wishes and autonomy.

[Nursing home directors' attitude toward medical decision-making and medical care for elderly people with dementia].

Medical decision-making involving elderly people with dementia often troubles care providers in Japan. Meanwhile, little attention has been paid to the routine medical care of nondementia illnesses in such patients. To understand the current situation surrounding the issue, we conducted a postal survey with nursing home directors across the nation. A self-administered questionnaire was sent to 1,117 randomly selected nursing homes, one third of all such facilities in Japan, and 502 (44.9%) responded. Of the respondents, 291 (58.0%) said more than a half of their residents have difficulties in daily life because of dementia. Less than 20% of the facilities said that they routinely confirm residents' preferences in writing when they are admitted concerning each of the following items; terminal care, medical information disclosure, leaving a will, funerals and application for the guardian system. 206 (41.0%) facilities have difficulties in finding a hospital for the elderly with dementia when necessary. The Mann-Whitney U test showed no significant relation between facilities' characteristics and their difficulties in finding a hospital that would admit demented patients. At present, a number of nursing homes confirm their residents' preferences only some time after they are admitted. However, the way of confirming seems inappropriate under the circumstances in which more than a majority of residents have difficulties in daily life due to dementia. Though more than a half of nursing homes have difficulties in finding a hospital that would admit dementia patients, no significant relation was found between the difficulties and the facility-hospital relation. The problem seems to lie in the acceptance mechanism of hospitals.

[Preliminary reports on psychiatric practice in correctional facilities].

In October 2001, Nanashakon, a council composed of seven psychiatry-related organizations in Japan, decided to launch an investigation into forensic psychiatry in Japan, and established a working team (WT) for this purpose. From its establishment to March 2004, the WT performed surveys and analyses of the current situation of preliminary reports by psychiatric experts (preliminary reports) and of psychiatric practice in correctional facilities. Based on the results, the WT has presented proposals including guidelines for preliminary reports. In January 2002, the WT conducted an awareness survey on the status quo of testimony by psychiatric experts and forensic psychiatry, targeting the members of the Japanese Society of Psychiatry and Neurology, and obtained 666 replies. The survey revealed various critical opinions such as skepticism over the current punishment imposed on criminal patients with mental disorders. In February 2002, the WT obtained data on preliminary reports (2,042 cases) compiled prior to prosecution in FY2000 from the Japanese Ministry of Justice. Reviewing the details and differences between the evaluation by psychiatrists and the decision by public prosecutors, the WT pointed out the ambiguity of criteria used for the evaluation of competency of weak-minded persons and the criteria for criminal punishment. Around the same time, the WT was also asked by a news agency to analyze the preliminary reports of 50 district public prosecutor offices. The results revealed marked regional differences in the operation of the preliminary evaluation system for competency. In January 2003, the WT collected 146 preliminary reports from around the country for comparison and review, and again found conspicuous individual and regional discrepancies in the format and content. Based on these results, the WT conducted a hearing of 41 expert opinions on preliminary reports, and in January 2004, proposed guidelines outlining a format model of preliminary reports, and a training and authorizing system for forensic psychiatrists, to standardize preliminary reports and enhance their reliability. In February 2004, the WT conducted a questionnaire survey on the current situation of psychiatry in correctional facilities, targeting doctors with experience working under these circumstances. Fifty-one replies were obtained. Most of the respondents approved of the current system. However, to incite arguments in this area, attempts were made to draw critical responses and discussion by presenting data on the current situation of psychiatric practice in correctional facilities.