Oral Intake in the Complete Lateral Position as a Compensatory Method for a Patient with Severe Dysphagia: A Case Report.

Background: We report a patient with severe dysphagia who was successfully treated using our newly developed swallowing rehabilitation method involving a complete lateral position. Case: This case involved a 74-year-old male patient with dysphagia caused by multiple morbidities, including sarcopenia after panperitonitis, Wallenberg syndrome, and Lewy body dementia. We attempted oral feeding in the complete lateral position and observed that the bolus was moving as intended and was swallowed without penetration or aspiration. The patient achieved oral feeding using the complete lateral position, and his physical and cognitive functions improved. He was discharged home and continued feeding orally without alternative means for more than 5 years. Discussion: In the flat (complete) lateral position, the bolus flows and pools as far as possible from the airway opening of the pharynx. Using this method, gravity aids in preventing penetration and aspiration. Therefore, eating in the complete lateral position has immediate effects that are reproducible and not dependent on the cognitive function or motor skills of the patient or the assistance skills of the caregivers.

Case series of elderly patients with scabies topically applied with ivermectin via whole-body bathing.

As a novel method of ivermectin (IVM) administration for the treatment of scabies, we devised a whole-body bathing (WBB), in which patients are immersed in a fluid that contains IVM. A multi-institutional trial for elderly patients with scabies was conducted to investigate the efficacy and safety of IVM-WBB. Seven elderly patients with scabies were enrolled and received IVM-WBB up to four times at 1-week interval. The cure for scabies was defined as the absence of mites in two consecutive microscopic or dermoscopic examinations at weekly intervals and the absence of new skin lesions indicative of scabies. Consequently, the cure rate on day 22, the primary end-point, was 71.4%, and all patients had been cured until day 29. Additionally, neither significant adverse events nor clinically problematic abnormal blood test values were obtained. Furthermore, no IVM was detected in the optional plasma (five cases) collected for IVM measurement after bathing. These results suggest that IVM-WBB was effective to treat scabies, causing no serious adverse events and with a very low internal exposure of IVM.

[Is intensive and comprehensive dysphagia rehabilitation effective in preventing hospital-acquired pneumonia in a convalescent rehabilitation ward?]

AIM: To evaluate the effect of intensive and comprehensive dysphagia rehabilitation on the prevention of hospital-acquired pneumonia. PATIENTS AND METHODS: In this non-randomized retrospective observational study, we compared two patient groups in a convalescent rehabilitation ward. One included patients after the introduction of an intensive and comprehensive rehabilitative program including various measures, such as nutritional support and respiratory physical therapy (intensive program group); the other included patients who had been admitted before the introduction of the above measures (control group). The primary endpoint was the onset of pneumonia during the hospital stay. A multivariate logistic regression analysis was used to determine the adjusted odds ratio for the relationship between dysphagia rehabilitation and pneumonia onset. RESULTS: In the intensive program group, 5 of 291 patients were diagnosed with pneumonia, while in the control group, 13 of 460 were diagnosed with pneumonia. The adjusted odds ratio for intensive and comprehensive dysphagia rehabilitation with respect to hospital-acquired pneumonia was 0.326 (95% confidence interval: 0.112-0.949, p=0.040). CONCLUSION: This intensive and comprehensive dysphagia rehabilitation program was thought to be effective in preventing hospital-acquired pneumonia in a convalescent rehabilitation ward.

Pharmacokinetics of ivermectin applied topically by whole-body bathing method in healthy volunteers.

As a novel administration method of ivermectin (IVM) for scabies treatment, we proposed a "whole-body bathing method (WBBM)". In this method, the patients would bathe themselves in a bathing fluid containing IVM at an effective concentration. Previously, we demonstrated that WBBM could deliver IVM to the skin but not to the plasma in rats. In the present study, to assess the clinical validity of the method an arm bathing examination (first trial) and a whole-body bathing examination (second trial) were conducted in healthy volunteers. In both the first and second trials, after bathing in fluid containing IVM, the exposure in the stratum corneum was higher compared with that after taking IVM p.o. as reported previously. IVM was not detected in plasma at any sampling point after the whole-body bathing in the second trial. Furthermore no serious adverse events were found. These results in both trials suggest that WBBM can deliver IVM to the human stratum corneum without systemic exposure or serious adverse effects in healthy volunteers, and at concentrations that would be adequate for scabies treatment.

Exploration of a standard treatment for Buruli ulcer through a comprehensive analysis of all cases diagnosed in Japan.

Buruli ulcer (BU) is a refractory skin ulcer caused by Mycobacterium ulcerans or M. ulcerans ssp. shinshuense, a subspecies thought to have originated in Japan or elsewhere in Asia. Although BU occurs most frequently in tropical and subtropical areas such as Africa and Australia, the occurrence in Japan has gradually increased in recent years. The World Health Organization recommends multidrug therapy consisting of a combination of oral rifampicin (RFP) and i.m. streptomycin (SM) for the treatment of BU. However, surgical interventions are often required when chemotherapy alone is ineffective. As a first step in developing a standardized regimen for BU treatment in Japan, we analyzed detailed records of treatments and prognoses in 40 of the 44 BU cases that have been diagnosed in Japan. We found that a combination of RFP (450 mg/day), levofloxacin (LVFX; 500 mg/day) and clarithromycin (CAM; at a dose of 800 mg/day instead of 400 mg/day) was superior to other chemotherapies performed in Japan. This simple treatment with oral medication increases the probability of patient adherence, and may often eliminate the need for surgery.

A 35-month prospective study on onset of scabies in a psychiatric hospital: discussion on patient transfer and incubation period.

This study was conducted to evaluate the risk factors of scabies introduction into a hospital. We addressed the following question: Do patients transferred from other institutions pose a higher risk than patients from the community? From July 2003 to May 2006, a trained physician surveyed the inpatients and staff of a psychiatric hospital (six wards, 300 beds) on a monthly basis. During the study period, specific infection control measures beyond standard precautions, such as prophylactic treatment, were not adopted. There were 333 newly-admitted patients during the study period and among them, 122 were transferred from other institutions. Seven patients were diagnosed with scabies. Two of these patients were infected while in the hospital (secondary infection), thus the number of introduced scabies cases (index cases) was five. Four of the index cases were transferred from other institutions (three from psychiatric hospitals and one from a nursing home). The source of infection for one index case was unexplained. The rate of scabies infection among transferred patients was 3.3% while the infection rate among patients from the community was 0.5%. Therefore, transferred patients pose a higher risk than those from the community. The average time from admission to diagnosis of scabies was 141 days (range 34-313 days). The hospital personnel checked the skin condition of all patients at admission and none of the four patients showed symptoms of scabies.

Risk factors for recurrence of scabies: a retrospective study of scabies patients in a long-term care hospital.

A considerable number of patients suffer recurrence of scabies. To elucidate risk factors for recurrence of scabies, we compared patients who experienced scabies recurrence and those who suffered scabies only once. We conducted a retrospective review of medical records of all scabies patients in a long-term care hospital for the elderly (300 beds; six wards) for a period of 42 months to determine frequency of scabies onsets, underlying diseases, history of treatment, and demographic data such as age and sex. One hundred and forty-eight patients and five hospital staff members suffered scabies during the 42-month study period. All staff members and 98 patients had no recurrence, while 50 patients experienced at least one recurrence of scabies. The cumulative number of scabies diagnoses was 228. The rates of scabies onset and recurrence were considerably different among wards. The dementia unit showed the highest rate of onset and recurrence. In addition to frequent exposure to infectious sources, problematic behavior, such as lying in other patients beds, might cause the high recurrence rate in dementia units. Higher serum total lymphocyte count and topical use of γ-benzene hexachloride were associated with lower risk of scabies recurrence. Recurrence of scabies is not uncommon among elderly patients in institutional settings. Impaired immunity may be a risk factor for recurrence of scabies. Groups with a high onset rate of scabies pose a high likelihood of recurrence. Problematic behavior of demented patients may increase the risk of recurrence. Use of effective topical treatment may effectively prevent recurrence.

Elective single-vessel percutaneous coronary intervention in a vegetative state patient.

A 73-year-old male in a persistent vegetative state underwent percutaneous coronary intervention (PCI) for unstable angina with multiple-vessel stenosis. The maximum dose pharmaceutical therapy was ineffective in controlling his symptoms. The goal of the procedure was to alleviate the patient's severe chest pain and vomiting with minimal invasion and risk. The procedure was effective despite treating only the culprit artery. Symptoms disappeared immediately after PCI and the patient remained attack free for 12 months. With the consent of the patient's family and support of medical staff, elective single-vessel PCI can be a practical and effective treatment option for refractory angina in patients with impaired consciousness.

Risk factors of scabies in psychiatric and long-term care hospitals: a nationwide mail-in survey in Japan.

Despite the commonness of scabies in Japanese institutional settings, the nationwide prevalence of scabies has not been elucidated. This study was conducted to assess the prevalence of scabies and control measures in Japanese hospitals. A questionnaire on scabies epidemiology (e.g. number of patients and onsets of outbreak) and preventive measures were sent to psychiatric hospitals and long-term care hospitals nationwide (n = 1795) in January 2005. Seven hundred and forty-one hospitals responded (41.3%). Three hundred and thirty-three (44.9%) respondent hospitals had one or more scabies cases in 2004. Among 159 hospitals that had experienced scabies outbreak, only 32 of them reported cases of crusted scabies. Multivariate regression analysis showed that hospitals had a greater number of beds, and that acute- and long-term care wards were more likely to experience scabies onsets. Hospitals that compiled their infection control manuals on scabies, treated suspicious patients with scabicides without confirmed diagnosis, and performed skin checkup of inpatients were more likely to experience scabies cases. Infection control personnel should be aware that unrecognized crusted scabies can cause outbreaks. Higher patient turnover is a risk factor for scabies introduction into a hospital. Preventive measures against scabies, such as patient screening at admission and treating all suspicious patients without confirmed diagnosis, were not effective to avoid scabies introduction.

[Terminal care education and consultation activities in advance of the critical stage of disease by attending physicians at a rehabilitation unit].

AIM: We aimed to examine the effectiveness of information provided by a physician to patients and their family in a geriatric rehabilitation unit for facilitating terminal care decision-making process. METHOD: The subjects were 338 patients who entered our rehabilitation unit between July 2005 and June 2007. Of the 338 patients, we provided terminal care consultation for 224 upon admission. We surveyed the 224 patients who received consultation as well as the 114 patients who did not, and examined the effect of the consultations on decision-making regarding terminal care. RESULTS: In both the intervention and non-intervention groups, approximately half of the patients' families had an opportunity to discuss terminal care prior to entering the hospital. The intervention group, however, had a significantly higher ratio (42.0%) of having the opportunity to discuss terminal care among their family members after leaving the hospital. In the non-intervention group, 31.4% had the knowledge of an artificial respirator and 37.1% tube feeding. This was low compared to the intervention group, among 60% understood both. Among the intervention group, there were many who desired these consultations to be provided far in advance of the critical stage of disease to allow more time to make end-of-life decisions. Furthermore, 60% of the intervention group indicated that the terminal care consultations were effective and useful. CONCLUSION: In light of these results, physicians should provide terminal care consultations before death is imminent. Since this will encourage self decision-making and help clarify the family's intentions, these kinds of consultations should be more actively implemented.

[Comparison of ability-based and performance-based IADL evaluation of community-dwelling elderly using the Kihon Checklist and TMIG Index of Competence].

AIM: Elderly populations are evaluated on their ability to perform instrumental activities of daily living (IADL) using one of three subscales in the Tokyo Metropolitan Institute of Gerontology (TMIG) Index of Competence, while the Kihon Checklist-a tool developed to screen for frailty-is designed to measure actual task performance. This study examined the significance of performance-based evaluations. METHODS: Using five items from the TMIG Index of Competence assessing ability, and three items included in the Kihon Checklist assessing performance, 124 community-dwelling elderly persons were evaluated in five daily task areas: using public transportation; shopping for daily necessities; handling bank accounts; paying bills; and preparing meals. Physical, psychological and social functioning were also assessed during the evaluations. RESULTS: The study revealed discrepancies between participants' abilities and their performance levels of the same daily tasks. Of the respondents, 12.5% men and 13.4% women reported that "they could perform all three tasks on the Kihon Checklist, but in actuality did not perform at least one of them". This "borderline-performance group" indicated a lower functioning level than those who answered "they performed all tasks" in all three physical, psychological and social domains. However, this group indicated a higher functioning level than those reporting that it was "impossible to perform at least one task" in all three domains. CONCLUSION: Study findings suggested that borderline-performance was related to the early stage of functional decline. The performance-based IADL evaluation is an effective screening tool for preventive declines in daily task performance.

[Nosocomial outbreak of scabies in a psychiatric hospital--epidemiological assessment and prophylactic treatment with oral ivermectin].

OBJECTIVES: To evaluate the effectiveness of mass treatment with ivermectin of scabies outbreak in institutional settings. To determine the factors, such as host susceptibility and scabetic exposure level associated with the onset of scabies. METHODS: The authors investigated a nosocomial scabies outbreak in a close psychiatric ward. The index case was a man with steroid-induced localized crusted scabies. Twenty-six patients were diagnosed with scabies, 4 of them had relapse of scabies, while no staff was infested. Despite frequent surveillance and treatment of symptomatic patients with 1% gamma-benzenehexachloride (gamma-BHC: Lindane), new cases were observed. Thus, all 69 patients in the ward were treated with ivermectin (200 microg/kg) simultaneously on day 105 of the outbreak (the mass treatment). Patients who had scabies were compared with patients who had no scabies in terms of age, body weight, diabetes, physical functions, topical administration of corticosteroid, proximity to the index patient, and problematic behavior. RESULTS: The mass treatment was implemented without a significant adverse event. Although two patients developed symptoms of scabies after the mass treatment, no patient in the ward had been diagnosed with scabies since the 98th day of the treatment. Regarding factors associated with the scabies onset, the only statistically significant factor was proximity to the index patient with crusted scabies. CONCLUSIONS: Oral ivermectin was safe and effective for controlling scabies in institutional settings. The exposure level to scabetic mites was more important than host susceptibility in determining the risk of scabies onset.