[Differential Diagnosis of Interstitial Pneumonia by Home Ultrasound Examination].

BACKGROUND: Patients receiving home care present clinically diverse forms of chronic respiratory failure, for which it is difficult to establish a definite diagnosis. CT diagnosis requires the patient to be transported, and obtaining the blood test results for the serum maker KL-6 requires a few days. Nevertheless, with the widespread use of portable ultrasound devices, we can now make an immediate ultrasound diagnosis of the lung in the home care setting. In our experience, most patients with deteriorated interstitialpneumonia show characteristic large disseminated B-lines or pleural effusion. This makes it possible to differentiate it from pneumonia, pulmonary emphysema, or cardiac insufficiency, which have similar clinical findings. PURPOSE: To consider the possibility of using ultrasonography for the differential diagnosis of interstitial pneumonia. SUBJECTS: Eighteen patients with chronic respiratory failure receiving home care underwent ultrasonography and blood test(serum KL-6). METHODS: We examined the presence or absence of pleural effusion and B-line in patients who underwent lung echocardiogram examination and had a serum KL-6 level greater or less than 500 U/mL. RESULTS: All 8 patients with KL-6 levels greater than 500 U/mL showed B-lines or pleural effusion. However, only 2 of the 10 patients with KL-6 levels less than 500 U/mL showed B-lines. CONCLUSION: Ultrasonography of patients with interstitial pneumonia, which is a cause of chronic respiratory failure, revealed a characteristic large and disseminated hyperechoic area. Although the number of patients was limited, we may consider ultrasonography effective for the diagnosis of interstitial pneumonia in the home care setting.

[Consideration of the Work Content of the Clinic Pharmacist and Its Usefulness].

"Medical teams"have been promoted in the home care setting. For the pharmacist, it is possible to maintain the safety and improve the quality of medical care by working with a multidisciplinary team. The arrangement of the pharmacist with the clinic is specified in Article 18 of the Medical Care Law, but there is no medical treatment fee for the clinic pharmacist. We examined the work content and usefulness of the clinic pharmacist. The work content was to participate in visiting consultation, introduce pharmacotherapy management based on the clinic pharmacist's working protocol, propose prescriptions, provide drug information service, and cooperate with insurance pharmacy pharmacists. Because the pharmacist was working in the clinic, he or she was able to actively intervene in drug treatment. Intervention in medication requires organizing and gathering information, which is difficult in the position of the insurance pharmacy pharmacist. The fact that the clinic pharmacist assumes this role and works with insurance pharmacy pharmacists makes it possible to maintain the safety and improve the quality of medical care.

Unresolved Palliative Care Needs of Elderly Non-Cancer Patients at Home: A Multicenter Prospective Study.

INTRODUCTION/OBJECTIVES: There is growing consensus on the benefits of initiating palliative care early in the disease trajectory; however, palliative care needs for non-cancer patients remain to be elucidated. We investigated the trajectory of unresolved palliative care needs of non-cancer patients at home and explored associated factors. METHODS: We conducted a multicenter prospective cohort study of elderly non-cancer patients at home in Japan between Jan 2020 and Dec 2020. Physicians assessed their palliative care needs using the Integrated Palliative Care Outcome Scale (IPOS). Unresolved palliative care needs were defined as IPOS symptoms above 2 (moderate). RESULTS: In total, 785 patients were enrolled. The most frequent unresolved palliative care needs at enrollment were poor mobility (n = 438, 55.8%), followed by weakness/lack of energy (n = 181, 23.1%) and poor appetite (n = 160, 20.4%). Multivariate logistic regression analysis revealed that female and musculoskeletal disease were significantly positively associated with pain at starting home visits (OR = 1.89, P = .015; OR = 2.69, P = .005). In addition, neurological diseases were significantly positively associated with constipation and poor mobility 3 months after starting home visits (OR = 3.75, P = .047; OR = 3.04, P = .009). CONCLUSIONS: The order of the prevalence of unresolved palliative care needs may remain relatively stable over time, even for those receiving home-based palliative care services. We identified several specific diseases and conditions that were significantly associated with unresolved palliative care needs.

[How to make sure a balloon-type gastrostomy replacement was made right by ultrasound].

With the spread of gastric fistula, there have been increased reports of catheter aberrant and fistula damage during the time of catheter exchange procedures. Therefore, it has been recommended that a diagnostic imaging or endoscopic gastrostomy should be employed to make sure a catheter exchange was properly done. However, it is difficult to enforce an inspection using an X-ray or endoscopy in the home care environment. Here we examined the usefulness and problems associated with ultrasound catheter-validation for home care environment. Of 33 patients who received gastrostomy, we focused on 6 patients who had gastrostomy exchanged at home. Four out of 6 patients with a balloon-type gastrostomy exchanged clearly confirmed a good result by ultra sound. However, a patient with bumper-type was unclear. The reason being unclear was due to the material and shape of the appearance by the echo. Left costal arch operations approach is to scan the probe along the left side of the abdomen below the costal arch, so that a replaced gastrostomy catheter could be confirmed by following the low echoic area of the spleen, stomach vault and into the stomach cavity. It is considered that ultrasound examination of the exchanged balloon-type gastrostomy was useful under a consideration of patient's health conditions.

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care.

BACKGROUND: Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death. METHODS: This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017. RESULTS: In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% - 6.3%) vs. 1.4% (0.7% - 2.3%) on admission (p < 0.001) and 7.6% (6.4% - 8.9%) vs. 5.4% (4.0% - 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms. CONCLUSIONS: There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.

[Introduction of Rapidtip BNP and Rapidpia--a clinical significance of rapid measurement BNP for home medicine care].

Dyspnea is a common symptom, and a heart failure is one of the most important preferred diagnoses of dyspnea. But it is difficult to undergo ECG, US, or other examination to diagnose a heart failure at the patient home, especially in the case of such examination was needed quickly or frequently. Rapidtip BNP and Rapidpia were invented in order to measure BNP rapidly at the patient home, or in the physician's car.

Surgical treatment of pseudoaneurysm of the sinus of valsalva after aortic valve replacement for active infective endocarditis.

Pseudoaneurysm is an uncommon and serious complication of infective endocarditis (IE). It is often fatal because of its rapid progress, high rates of rupture and recurrence, and worsening effects on the systemic condition. We report the rare case of a patient who developed a pseudoaneurysm of the sinus of Valsalva two months after emergency aortic valve replacement for active IE. At the previous operation, we had directly closed a small fistulous hole in the non-coronary sinus of Valsalva using two mattress sutures with autologous pericardial pledgets, because the tissue surrounding the hole did not appear to be infected on visual inspection. A pseudoaneurysm developed from this portion due to detachment of sutures. If the fistula had been completely resected during the first surgery instead of performing a simple closure, the pseudoaneurysm of the sinus of Valsalva would not have formed. However, the primary aim of the first emergency surgery was to spare the life of a critically ill patient. In the second surgery, the pseudoaneurysm was completely resected with the aortic wall--including the non-coronary sinus of Valsalva and the communicating hole. Then, patch plasty of the non-Valsalva sinus was successfully performed.

Omental herniation through the esophageal hiatus mimics mediastinal lipomatous tumor.

A 61-year-old man with a mediastinal abnormal mass on computed tomography is presented. Sagittal sections of magnetic resonance imaging (MRI) clearly indicated the continuity of the fatty mass from the abdomen to the thorax. The diagnosis was an omental herniation through the esophageal hiatus during the operation. First, we returned the omentum into the abdominal cavity, and then repaired the hiatus. The patient had an uneventful postoperative recovery. A herniation of the omentum through the esophageal hiatus is rare; this case is the tenth found in both English and Japanese literatures. The coronal and sagittal planes of MRI were useful in distinguishing the herniation of omentum through the esophageal hiatus from lipomatous tumor. It is our intention of raising awareness about the disease.