Differences in perceived autonomy among American and Japanese older adults.

Perceived autonomy refers to perceived personal self-governance, or rather that a person feels free from external constraint to determine his or her own actions and behaviors. This study examined perceived autonomy among community-dwelling older adults residing in New York City and West Japan. A cross-sectional design was adopted using self-reports from 340 older adults (n = 220 Japanese, n = 120 Americans) recruited from senior centers. Perceived autonomy was quantified with the Hertz Perceived Enactment of Autonomy Scale (HPEAS), which includes three subscales: voluntariness, individuality, and self-direction. Compared to American respondents, more Japanese respondents were male (67.7% vs. 40.8%), more likely to live with others (78% vs. 25.7%), reported lower perceived autonomy (86.9 vs. 109.5), and scored lower on all three subscales of the HPEAS. Despite significant differences in perceived autonomy, a sociocultural factor such as social support was identified as an important factor for older adults in both groups.

Care managers' views on death and caring for older cancer patients in Japan.

Care managers (CMs) have an important role in coordinating care for cancer patients who are in the end-of-life stage; however, little is known about their views of death and their experiences while caring for older cancer patients. This study was conducted to examine CMs' views of death and caring for older cancer patients in a home care setting in Japan. Convenience sampling was undertaken, and 35 offices from 43 approached services agreed to participate. The final valid sample included responses from 136 CMs (90.7%). Most CMs, including nurses, care workers, home helpers, and social workers in home care settings, experienced difficulty in managing the care of cancer patients in the end-of-life stage. Respondents reported a wide array of experiences with end-of-life care, care management, and seminar attendance, and their ages and Frommelt Attitude Toward Care of the Dying (FATCOD) scores were associated factors. Moreover, multiple regression analysis indicated that better attitudes toward caring for the dying were positively associated with seminar attendance. These results suggest that CMs need education about palliative and end-of-life care in order to promote good home care for cancer patients.

Nurses' symptom management and views on death and caring for heart failure and chronic obstructive pulmonary disease.

BACKGROUND: The number of older adult patients in Japan is increasing and symptom management is needed not only for cancer patients, but also non-cancer patients. AIMS: This study investigated nurses' symptom management and their views on death and caring for heart failure (HF) and chronic obstructive pulmonary disease (COPD). METHODS: A cross-sectional survey using a questionnaire was conducted. Survey items were implementation of assessment and non-pharmacological interventions for 14 symptoms at the end-of-life stage, participation in palliative care training courses and attitude toward death and caring, as assessed by the Frommelt attitude toward care of the dying (FATCOD) Scale. RESULTS: A total of 266 (78.5%) nurses responded. More than 90% implemented symptom assessment of dyspnea and cough for both HF and COPD. The mean FATCOD score was 114.7, participation in on-the-job palliative care training courses (p<0.01), and difficulty with near-death issues (p<0.01) were significantly associated with the FATCOD. CONCLUSION: These results suggest that nurses assessed the major symptoms of HF and COPD. Training courses are important to promote palliative care for non-cancer patients.

Group G Streptococcal Necrotizing Soft Tissue Infection: A Pitfall of Rapid Antigen Detection Test for Group A.

Background: Necrotizing soft tissue infection (NSTI) caused by group A Streptococcus (GAS) is a life-threatening disease with high morbidity and mortality. Recently, group G Streptococcus (GGS) is increasingly reported as a cause of NSTI, which shows a similar fatality rate. A rapid antigen detection test (RADT) was used for GAS-induced NSTI to assist in the immediate diagnosis when judging the need for debridement surgery. Methods: We describe 2 NSTI cases in which an RADT for GAS was negative, and in which GGS-induced NSTI was subsequently diagnosed. Both cases involved patients over 80 years of age whose medical histories included multiple conditions, including cardiac disorder and lower leg disease. After making a 1-cm skin incision at the central part of erythema, samples for both a wound culture and an RADT for GAS were taken from the subcutaneous layer. Results: The RADTs were negative; however, the rapidly progressing clinical courses suggested the need for immediate debridement surgeries under general anesthesia. Removal of the skin and subcutaneous tissue and an incision for drainage achieved limb salvage. Wound cultures identified Group G Streptococcus (Streptococcus dysgalactiae) without other bacteria. Negative pressure wound therapy and split-layer mesh skin graft surgery cured the severe wounds without the need for amputation. Conclusions: Surgeons must be aware of the limitations of the RADT for GAS and determine the appropriate initial treatment based on comprehensive physical and laboratory findings.

Group A Streptococcal Rapid Antigen Detection Test: A Clinical Study to Evaluate the Reproducibility Using Human Wound Samples.

Background: The early diagnosis of necrotizing soft tissue infection (NSTI) caused by group A streptococcus (GAS) for performing debridement surgery is key to the patient survival. In 1996, the diversional use of a GAS-rapid antigen detection test (RADT) for pharyngitis was reported, quickly spreading as a clinically useful method. However, no clinical study has evaluated the reliability of RADT by using wound samples. This is the first study using clinical wound samples to examine the reproducibility between GAS-RADT and wound culture. Methods: Patients in whom wound culture samples were clinically necessary were included in this study. Two samples were obtained simultaneously: one for isolation of bacteria as wound culture and the other for GAS-RADT, with written informed consent. The reproducibility between GAS-RADT and wound culture was statistically evaluated by Cohen's kappa coefficient. Results: One hundred samples from 94 patients were collected from 2020 to 2021. Two samples were GAS-positive on wound culture, and both were RADT-positive (positive reproducibility: 100%). Ninety-eight samples were GAS-negative on wound culture; of these, 97 were RADT-negative (negative reproducibility: 99%). Cohen's kappa coefficient was 0.80, indicating excellent agreement beyond chance. None of the bacteria showed cross-reactional influences. The only discrepant case (RADT-positive and wound culture-negative) was attributed to the administration of antibiotics for 2 days before the sampling. Conclusions: The reproducibility between GAS-RADT and wound culture was statistically excellent, underscoring the reliability of GAS-RADT for wounds.

Less-invasive Treatment for Group A Streptococcal Fasciitis with Rapid Antigen Detection Test and Collagen/Gelatin Sponge.

Patients with severe group A Streptococcus (GAS) induced necrotizing soft tissue infection sometimes develop Streptococcal toxic shock syndrome, which is a life-threatening condition with an extremely high fatality rate. Obtaining survival is the most important goal; however, an early diagnosis for debridement surgery and quick granulation formation for skin grafting surgery can better preserve the extremity functions. The patient was a 47-year-old man with a history of atopic dermatitis who presented with GAS-induced necrotizing soft tissue infection in his left lower extremity. His vital signs indicated shock, and he was diagnosed with streptococcal toxic shock syndrome. Emergency surgery was performed with his body pressure maintained with noradrenaline. Intraoperatively, rapid antigen detection tests (RADTs) were negative in the medial thigh and positive in the lower leg, which helped in decision-making regarding the area of aggressive debridement surgery. The wound culture results matched the intraoperative rapid antigen detection test results. A collagen/gelatin sponge with the sustained release of basic fibroblast growth factor was used as an artificial dermis before skin grafting. Excellent granulation was obtained, and skin grafting surgery was performed on the 11th day after collagen/gelatin sponge placement. He was discharged home on the 42nd day with normal lower extremity functions. First, an intraoperative diagnosis using GAS-rapid antigen detection tests with an appropriate sampling method from small incisions avoided excessive surgical debridement. Second, collagen/gelatin sponge with the sustained release of basic fibroblast growth factor promoted quick granulation tissue formation for wound bed preparation. These efforts resulted in the successful less-invasive treatment of a patient with streptococcal toxic shock syndrome caused by GAS-induced necrotizing soft tissue infection.

Fournier's Gangrene with Edwardsiella tarda: A Gas Production Case by Bacterial Synergism with Streptococcus anginosus.

Edwardsiella tarda is an anaerobe associated with freshwater and marine life. Necrotizing soft tissue infection caused by E. tarda is rare, but its mortality rate is extremely high (61.1%). We experienced a survival case of Fournier's gangrene with E. tarda. A key clinical feature for the diagnosis was gas production; however, there have been no previous reports of such a phenomenon in relation to E. tarda. A 64-year-old man was admitted with a 3-day history of a high fever. His medical history, which included paraplegia from the Th6 level down, made the focus of inflammation at the perineum difficult to notice. Whole-body CT revealed subcutaneous gas from the posterior scrotum around the entire circumference of the anus. During emergency surgery, an incision at the posterior scrotum revealed extensive fascia necrosis, and E. tarda and Streptococcus anginosus were identified. We speculated the gas production in this case to be the product of a mixed infection of aerobes and anaerobes, which acted synergistically to induce bacterial growth. Timely surgical debridement and antibiotic therapy led to the patient's survival.

Nurses' and care workers' attitudes toward death and caring for dying older adults in Japan.

Registered nurses (RNs) and care workers (CWs) have important roles in providing end-of-life care to older adults, but little is known about the attitudes of RNs and CWs in Japan. In this study, 464 RNs and CWs working in facilities in Japan were asked to complete a self-administered questionnaire that included the Frommelt Attitude Toward Care of the Dying Scale, Form B, Japanese version (FATCOD-Form B-J) and the Death Attitude Profile (DAP), Japanese version. A total of 388 (83.6%) questionnaires were returned, and 367 (79.1%) were fully completed. The final sample included 190 RNs and 177 CWs. Multiple regression analysis showed that better attitudes toward caring for the dying were positively associated with seminar attendance and negatively associated with fear of death.

Effectiveness of end-of-life education among community-dwelling older adults.

The purpose of this study was to evaluate the effectiveness of an educational intervention regarding end-of-life discussion directed at older Japanese adults and their attitude to and acceptance of this intervention. A quasi-experimental design was used. A total of 121 older adults, aged 65 years and over, consented to participate. Data from 55 intervention and 57 control participants were used for the analysis. The intervention consisted of an education program comprising a video, a lecture using a handout, and discussion among participants. The control group received only the handout. Both groups were followed up after one month. The intervention group's attitude became more favorable towards advance directives, especially living wills (P = 0.024). In addition, their expression of preference for life-sustaining treatment by means of artificial nutrition was less at follow up, demonstrating that these older adults had become more autonomous (P = 0.008). There was greater acceptance of the intervention as a whole by the intervention group compared with the control group (P = 0.011). Although few participants overall completed living wills, at follow up twice as many in the intervention group had discussed end-of-life matters with family members and/or their physician.

Limitations of a Rapid Antigen Detection Test in the Early Diagnosis of Group A Streptococcal Necrotizing Soft Tissue Infection.

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Comparison of end-of-life preferences between Japanese elders in the United States and Japan.

Significant attention is being paid to end-of-life preferences and their cultural variations. This study compares end-of-life preferences between older Japanese residing in Japan and the United States. A self-administered questionnaire was provided to elders affiliated with senior centers and clubs. Japanese Americans preferred to make decisions themselves about withholding life-sustaining treatments, whereas Japanese in Japan preferred to rely on physicians and family members. The U.S. sample showed more positive attitudes toward and higher completion rates of advance directives than the Japanese sample. Results suggest that end-of-life preferences differ between Japanese elders in the two countries and that preferences are influenced by contextual factors in one's country of residence. Practitioners need to be aware of both within-group and across-group diversity in end-of-life preferences, taking into account acculturation changes.

Analysis of possible structures of inducible skin-associated lymphoid tissue in lupus erythematosus profundus.

Lupus erythematosus profundus (LEP) is a variant of lupus erythematosus, involving the deep dermis and subcutaneous fat. LEP is characterized by the presence of lymphoid follicles (LF) and germinal centers (GC). However, it remains unknown whether these lymphoid structures correspond to the lymphoid tissues such as cutaneous tertiary lymphoid organs (TLO). Previously, we identified dynamically orchestrated cellular elements in murine contact dermatitis that resembled lymphoid structures, which we termed inducible skin-associated lymphoid tissues (iSALT). We subsequently reported structures analogous to iSALT in human secondary syphilis, suggesting that iSALT can also exist in humans. Here, we studied ectopic lymphoid tissues in the lesions of LEP by immunohistochemistry and compared their characteristics with those of TLO. We demonstrated that LF of LEP were composed of B-cell follicles intermingled with CXCL13-expressing cells, distinct aggregations of T cells, and some blood vessels expressing peripheral node addressin. These findings indicate that LF of LEP can be considered as a type of iSALT.

SAR of 4-Alkoxybenzoic Acid Inhibitors of the Trypanosome Alternative Oxidase.

The SAR of 4-hydroxybenzaldehyde inhibitors of the trypanosome alternative oxidase (TAO), a critical enzyme for the respiration of bloodstream forms of trypanosomes, was investigated. Replacing the aldehyde group with a methyl ester resulted in a 10-fold increase in TAO inhibition and activity against T. brucei. Remarkably, two analogues containing the 2-hydroxy-6-methyl scaffold (9e and 16e) displayed single digit nanomolar TAO inhibition, which constitute the most potent 4-alkoxybenzoic acid derivatives described to date. 9e was 50-times more potent against TAO and 10-times more active against T. brucei compared to its benzaldehyde analogue 1. The farnesyl derivative 16e was as potent a TAO inhibitor as ascofuranone with IC50 = 3.1 nM. Similar to ascofuranone derivatives, the 2-hydroxy and 6-methyl groups seemed essential for low nanomolar TAO inhibition of acid derivatives, suggesting analogous binding interactions with the TAO active site.

Stereoselective Photoinduced Electron-Transfer Reactions of Zinc Myoglobin with Optically Active Viologens.

Photoinduced electron-transfer reactions between zinc-substituted myoglobin and optically active viologens and bisviologens, containing ((naphthyl-, ((phenyl-, and ((cyclohexyl)ethyl)carbamoyl)methyl groups, have been studied at 25 degrees C, pH 7.0 (a 0.01 M phosphate buffer), and various ionic strengths. The excited triplet state of zinc myoglobin was preferentially quenched by (S,S)-isomers of optically active viologens; both ratios of the quenching rate constants and back-electron-transfer rate constants, k((S,S))/k((R,R)), range from 1.1 to 1.5 at an ionic strength of 0.02 M with the order naphthyl > phenyl >/= cyclohexyl for the substituents. Stereoselectivity decreased with increasing ionic strengths. The steric bulk of the substituents of viologen may induce the conformational change of zinc myoglobin more effectively due to the steric repulsion between naphthyl groups and the polypeptide chain of zinc myoglobin.

Keeping vulnerable elderly patients free from pressure ulcer is associated with high caregiver burden in informal caregivers.

RATIONALE AND OBJECTIVES: The effect of the presence of pressure ulcers on burden of caregivers is unknown. We investigated the relationship between the state of pressure ulcers in vulnerable elderly patients and the burden on their informal caregivers. METHODS: This cross-sectional study enrolled 137 patients aged > or = 40 years with limited activity and mobility at 10 home care service facilities in Japan. We assessed pressure ulcer status from medical records and caregiver burden using scores from both the Burden Index of Caregivers (BIC) and the Japanese short version of the Zarit Burden Interview (ZBI). RESULTS: Among patients, mean age was 80.9 years, 31.4% were men, and 83.9% were free from pressure ulcers. Multivariable analysis showed that caregivers whose patients were free from pressure ulcers had significantly higher caregiver burden as assessed by both the BIC [beta-coefficient = 3.18, 95% confidence interval (CI): 1.42-4.95, P = 0.003] and ZBI scores (beta-coefficient = 1.94; 95%CI = 0.30-3.58; P = 0.03). CONCLUSIONS: Our results suggest that the continuous effort involved in keeping patients free from pressure ulcers may be associated with high caregiver burden in informal caregivers.

Perceived autonomy and self-care resources among senior center users.

Personal autonomy-the ability to make freely self-directed choices in one's life-is considered critical to an older person's quality of life. Informed by model and role-modeling nursing theory, this descriptive, correlational study examined the relationship of perceived enactment of autonomy to self-care resources, both internal (age, race, functional ability) and external (social support, living arrangements, community-based service utilization, and service satisfaction) among 120 older adults from 6 Manhattan senior centers. Participants demonstrated positive perceived autonomy. Study participants used a variety of community-based services, and their satisfaction with the services was significantly linked to autonomy. Using multiple linear regression model, the only significant predictors of perceived autonomy were race (white > nonwhite), service satisfaction, and social support. Nursing strategies such as providing information that promotes informed decision making and encouraging independence, as well as working collaboratively with members of an older persons' social network, can enhance an older persons' autonomy.

Perspectives of elderly people on advance directives in Japan.

PURPOSE: To examine perspectives of Japanese elderly people on advance directives (ADs) and factors related to positive attitudes toward ADs. METHOD: The data were collected by a structured questionnaire from 313 of 565 older adult members of senior citizens' centers in two cities in Japan. Survey items pertained to demographic characteristics, terminal care preferences, and personal values, including autonomy, family function, and religious piety. FINDINGS: Of the 313 elderly people who completed questionnaires, 72.9% had positive preferences for executing living wills. With regard to durable power of attorney for health care, 62.2% approved of it. The supporters of ADs were more likely to have had discussions about terminal care with family members or physicians, experience of a family member hospitalized for terminal illness or injury, preferences for life-sustaining treatments that were self-determined, and personal values such as religious piety. The relationship between positive preferences toward durable power of attorney for health care and sex, marital status, and living arrangements were significant. CONCLUSIONS: Most Japanese older adults in this study approved of ADs, and family structure was important to the acceptance of designating a proxy. Discussion about end-of-life care and respect for life-sustaining treatment preferences are important decisions, about the end of life.