PURPOSE: In Japan, about 80% of deaths occur in hospitals, especially long-term care beds. The purpose of this study was to clarify the nursing practices used for such older patients at the end-of-life stage in long-termcare wards via the modified grounded theory approach (M-GTA). METHODS: Data were obtained through semi-structured interviews of nineteen nurses working in cooperating long-term care wards, acute care wards, or hospice services (to allow for constant comparison between these types of wards) in western Japan in 2014. We analyzed the transcribed data using M-GTA. RESULTS: The core category that emerged from the analysis was “Balancing enhancement of patients' daily life quality and life-sustaining care in the face of uncertainty about the patients' character.” Eleven categories emerged, such as Seeking older patients' character with their family, Supporting families' decision making, Rebuilding patients' daily life in the ward, and Sustaining patients' life span through medical care. CONCLUSIONS: Nurses experienced uncertainty about the care needs of older patients, the ethical problems of Enhancing the patients' QOL by using risky care, and the evaluation criteria used to judge their own nursing care after the patients' death. All nurses had the goal of ensuring a natural death for all patients. Nurses' acceptance and evaluation of their own care was critically influenced by the patient's family's responses to their care after patients' death. Further research is necessary to develop evaluation criteria and educational programs for end-of-life nursing care of older adults.
Adult ; Decision Making ; Grounded Theory ; Hospices ; Humans ; Japan* ; Long-Term Care* ; Nursing ; Nursing Care ; Qualitative Research ; Quality of Life* ; Terminal Care ; Uncertainty

Objective : To investigate the safety and effects of long-term administration of denopamine, β-1 stimulant, on the activities of daily living in heart failure patients.
Design : Case-series.
Methods : One hundred forty patients with mild to moderate chronic heart failure were administered denopamine at dose of 5 to 10 mg three times daily for 24 weeks. Concomitant circulatory system drugs such as digitalis, diuretics, vasodilator drugs, etc., were used without changing the administration method and dose. However, the use of a concomitant β-blocker was prohibited.
Results : Following administration of denopamine, the NYHA cardiac function classification improved by one degree or more in 50 patients (35.7%). The body weight decreased significantly from 54.9± 10.2kg (mean±SD) before administration to 54.0±10.2kg after administration (P<0.05), and the cardiothoracic ratio also decreased from 58.0±7.3% to 56.6±7.2% (P<0.001). No significant changes were observed in the heart rate, systolic blood pressure, or diastolic blood pressure. The activities of daily living improved by one level or more for 49 patients (51.6%). There were 36 withdrawal or dropout cases (patients' own convenience : 12 cases ; complications/accidental symptoms : 7 cases) during the investigation period. Four patients (2.9%) exhibited adverse reactions.
Conclusion : Denopamine seemed to improve the quality of life, which is one of the therapeutic purposes for patients with chronic cardiac failure. A large-scale study including investigation of the long-term prognosis for such patients needs to be performed.

We report a case of systemic sclerosis complicated with primary biliary cirrhosis successfully treated with orengedokuto (wanbinghuichun) and sekiganryo. The patient was a 68-year-old female. She had been diagnosed with systemic sclerosis 20 years previously, and primary biliary cirrhosis 17 years previously. She received modern Western medical treatment for skin itching and scleroderma, but her symptoms showed little improvement. Therefore, she consulted our clinic in order to receive Kampo therapy. We prescribed orengedokuto (wanbinghuichun), and the skin itching improved in 5 days. As a result of administering sekiganryo in addition to orengedokuto (wanbinghuichun) for severe coldness, the scleroderma was also ameliorated. We consider this to be a case of diseases overlapping between yin and yang syndrome.

Trigger finger develops because of stenosis around the A1 annular ligament, which causes inhibition of smooth expansion and contraction of the finger. It is effectively treated by an anti-inflammatory analgesic and/or steroid infusion, and by Western style medical surgery. Here, we report 3 cases of trigger finger effectively treated with unkeito. The first case was a 71-year-old female who had been treated with Kampo medicine for an enlarged feeling in the abdomen. She complained of trigger finger, in the knuckle of her right third finger, dry lips, and hot flashes in her hands and feet. The second case was a 56-year-old female who had been treated with Kampo medicine for polyarticular pain in her fingers. She complained of trigger finger of the left fourth finger and hot flashes in her hands. The third case was a 71-year-old female who had been treated for chronic renal failure. She complained of trigger finger in the left first finger and dry skin but had neither hot flashes in the hands nor dry lips. One of the target symptoms of unkeito is hot flashes in the hands and dry lips. Unkeito is composed of herbs which improve ketsu deficiency, oketsu, inflammation, and dry skin. It is possible that these actions of unkeito are effective in trigger finger as well.

Background/Aims: Intralesional steroid injections have been administered as prophylaxis for stenosis after esophageal endoscopic submucosal dissection. However, this method carries a risk of potential complications such as perforation because a fine needle is used to directly puncture the postoperative ulcer. We devised a new method of steroid intralesional infusion using a spray tube and evaluated its efficacy and safety. Methods: Intralesional steroid infusion using a spray tube was performed on 27 patients who underwent endoscopic submucosal dissection for superficial esophageal cancer with three-quarters or more of the lumen circumference resected. The presence or absence of stenosis, complications, and the number of endoscopic balloon dilations (EBDs) performed were evaluated after treatment. Results: Although stenosis was not observed in 22 of the 27 patients, five patients had stenosis and dysphagia requiring EBD. The stenosis in these five patients was relieved after four EBDs. No complications related to intralesional steroid infusion using the spray tube were observed. Conclusions Intralesional steroid infusion using a spray tube is a simple and safe technique that is adequately effective in preventing stenosis Clinical trial number (UMIN000037567).

Objective: To clarify changes in the quality of life (QOL) of ambulatory patients with locally advanced/metastatic cancer who underwent rehabilitation in a palliative care unit. Methods: Patients aged 18 years or older who were admitted to the Palliative Care Unit, had a Functional Ambulation Category of 1 (assisted ambulation) or higher, and were assessed at admission and two weeks after admission using the Comprehensive Quality of Life Outcome (CoQoLo) short version, were included in the study. Results: Twenty-one patients completed the 2-week assessment. Ten subjects were male, with a median age of 78 years. The Functional Independence Measure cognitive items significantly declined 2 weeks after admission, but the CoQoLo total score was not significantly different. In addition, the rate of change in the CoQoLo item “Being respected as an individual” was significantly higher in the ≥4 days/week rehabilitation intervention group than in the <4 days/week group. Conclusion: This study has shown that it is possible to maintain the QOL of ambulatory patients with cancer who received rehabilitation in a palliative care unit.

Objective: This study explored the factors influencing commissioned welfare volunteers’ (CWVs) attitudes toward mental illnesses and how their attitudes correlated with their social distance from people with mental illness.Materials and Methods: Data from 223 CWVs were analyzed statistically. Factor extractions for the Image for Mental Illness Scale (IMI) and Social Distance Scale (SDS) were calculated. We examined the relations between factors in IMI and SDS.Results: CWVs’ attitudes were classified as Understanding (understanding of the condition), Secure (feelings of safety in the presence of those with mental illness), and Activity (reactions to the behaviors of people with mental illness). Social distance from those with mental illness was classified as Public and Private Interactions. CWVs’ interactions with people with mental illness were significantly influenced by feeling Secure in the presence of the latter. Low Public and Private Interactions were influenced by older age. CWVs’ “experience in providing consultations for mental illness” led to the avoidance of Private Interactions.Conclusion: CWVs should feel safe when involved in Public or Private Interactions with individuals with mental illness. CWVs reported a preference for a higher level of social distance from people with mental illness.

A 62-year-old man presented with hemoptysis and hoarseness. He was diagnosed with an aortopulmonary fistula due to a thoracic aortic aneurysm rupture and was referred to our department. Emergency in-situ reconstruction of the aorta and pulmonary lobectomy were performed. Nine days postoperative, he developed empyema. Intrapleural urokinase and antibiotic therapy were selected as management instead of a video-assisted thoracoscopic debridement and decortication due to his worsening condition. The treatment was successful, and he was discharged from the hospital without any further complications. This study highlights the benefit of intrapleural administration of urokinase and antibiotics in patients with acute empyema, when surgical treatment is inappropriate.

Background: In the case of refractory diarrhea that cannot be treated with loperamide only, drugs such as octreotide and serotonin receptor antagonists are generally recommended. We have reported a case of refractory diarrhea associated with carcinoid syndrome in which symptoms improved only with opioid switching, without octreotide. Case: We experienced a case of a 28-year-old female with cervical cancer. She was diagnosed with recurrence after cervical cancer surgery and presented with pain and diarrhea. Her diarrhea did not improve sufficiently after taking loperamide. She was admitted to the palliative care hospital for symptom control due to persistent diarrhea and right lower extremity pain associated with bone metastasis. We diagnosed the cause of her diarrhea as carcinoid syndrome by some laboratory examination. For pain management, we switched opioids from transdermal fentanyl to continuous subcutaneous infusion of morphine. It resulted in pain relief and improvement in the frequency of diarrhea, and she was able to be discharged home. Conclusion: In cases of refractory diarrhea and in patients who need opioids, there is one option to use morphine. If it is effective, it may simply resolve both pain and diarrhea and reduce the use of multiple medications.

A 77-year-old woman underwent endovascular abdominal aortic repair (EVAR) for an abdominal aortic aneurysm (AAA)．Five years after surgery, she visited the hospital with the chief complaint of a fever. Enhanced computed tomography (CT) showed enlargement of the AAA around the stent-graft and a mass, which was suspected to be an abscess, outside the aneurysm. A blood test revealed a high level of inflammatory response. The patient was diagnosed with infectious AAA. She received antibiotics; however, the inflammatory response did not completely improve. A second CT scan revealed that the suspected abscess had a spreading tendency. The patient was referred to our hospital for a highly suspected stent-graft infection. We performed Y-graft replacement using a rifampicin-immersed graft, and as much as possible of the wall around the aortic aneurysm was removed. The inflammatory response improved rapidly after the operation, and the patient was discharged 15 days later. According to the results of a pathological examination, a diagnosis of xanthogranulomatous inflammation and fibrosis was made. Here, we report a rare case of xanthogranulomatous inflammation of the aortic aneurysm wall after EVAR.