Actual conditions for returning home after hospitalization among older patients receiving home medical care in Japan: OHCARE Study.

AIM: To examine the actual conditions of older patients receiving home medical care after hospitalization over a period of 2 years in Japan. METHODS: The study population included 102 participants, aged ≥65 years, receiving home medical care, who consented to participate in the Osaka Home Care Registry (OHCARE) study in Japan over a period of 2 years. We investigated the actual conditions for returning home after hospitalization. RESULTS: The median age of the 102 participants was 84 years, and 61 (59.8%) were women. In the group that returned home, 42 (55.3%) of the respondents desired to recuperate in a familiar place, as in advanced care planning (ACP). During the 2-year follow-up period, the group that did not return home had significantly more deaths. A multivariate analysis showed the association in the presence of ACP (odds ratio: 4.72, 95% confidence interval: 1.60-13.86) and cardiac disease (odds ratio: 0.25, 95% confidence interval: 0.08-0.76). The lack of ACP in the medical records when the patient was admitted to the hospital may have prevented the return home. CONCLUSION: In older patients who had difficulty returning home after hospitalization, the lack of ACP in home medical care may have been an influencing factor. ACP could help continue with home medical care. Geriatr Gerontol Int 2024; 24: 320-326.

[Seasonal changes in blood pressure and related factors among older patients receiving home medical care].

AIM: We investigated seasonal variations in blood pressure (BP) and factors related to these variations among older patients receiving home medical care. METHOD: A total 57 patients ≥ 65 years old receiving home medical care who participated in the Osaka Home Care REgistry study (OHCARE), a prospective cohort study, were included. We investigated the seasonal patient characteristics and variations in the BP. In addition, to determine the influence of seasonal variations in the systolic blood pressure (SBP) on the occurrence of clinical events (hospitalization, falls and death), we classified patients into larger- and smaller- change groups based on the median seasonal variations in SBP. RESULT: About 60% of subjects were very frail or bedridden. The mean BP was higher in winter than in summer (124.7±11/69.5±7 vs.120.5±12/66.9±8 mmHg) (P< 0.01). On comparing the characteristics of the two groups with larger and smaller changes in the SBP, the group with large BP changes had a significantly lower BP in summer than the group with small BP changes. In addition, the incidence of "hospitalization" was significantly higher in the group with large BP changes than in the group with small BP changes (P = 0.03). CONCLUSION: The present study revealed that there were seasonal changes in the BP in older patients receiving home medical care. It was also suggested that seasonal changes in the BP might be associated with the risk of hospitalization events. Given these BP variations, doctors and visiting nurses should be alert for systemic abnormalities, especially in frail patients receinving home medical care.

Associations of blood pressure levels with clinical events in older patients receiving home medical care.

Some studies reported that excessive blood pressure (BP) control was not appropriate for older people, especially from the viewpoint of quality of life and maintaining sufficient blood flow for tissue perfusion. However, the lower limit of the target BP is still unclear, and there has not yet been a sufficient consensus. Therefore, we investigated the associations of BP levels with clinical events in older patients ~85 years old receiving home medical care. A total of 144 patients were included, who were followed for longer than 3 months in the Osaka Home Care Registry study, a prospective cohort study targeting older patients receiving home medical care in Japan. BP levels were divided into lower and higher groups based on the average systolic blood pressure (SBP). The main outcomes were clinical events, including hospitalizations, falls, and deaths during follow-up. As a result, the hospitalization rate in the SBP below 124 mmHg group was significantly higher than that in the SBP over 124 mmHg group. When comparing the clinical events between the two groups only in participants with hypertension, the same results were obtained. Furthermore, in Cox proportional hazards regression models adjusted by age, sex, and current diseases, the SBP below 124 mmHg group showed a significantly higher rate of required hospitalization (hazard ratio: 7.25, 95% confidence interval: 1.79-29.45). Thus, in older and very frail patients requiring home medical care, an SBP level below 124 mmHg could be a predictive marker of clinical events leading to hospitalization.

[Factors associated with behavioral and psychological symptoms in patients with dementia who received home medical treatment: A cross-sectional study (OHCARE study)].

AIM: The present study investigated the behavioral and psychological symptoms of dementia (BPSD) and pharmacological therapy among elderly people with dementia who received home medical treatment. METHODS: This study was part of the Osaka Home Care Registry study (OHCARE-study). Participants were >65 years old with dementia. Demographic and medical data, BPSD, and the LTCI [long-term care insurance] care-need level were collected. A multiple logistic regression analysis was performed in order to clarify the factors associated with BPSD. RESULTS: Among 110 subjects (82.0±11.3 years old), 64.6% had a diagnosis of dementia, most commonly Alzheimer's dementia. Aside from home medical treatment, 58.1% had a nurse visit, 48.1% received home care, and 40.0% used a day service. The prevalence of BPSD was 53.0%. Those with BPSD most frequently had an LTCI care-need level of 3, and the prevalence of BPSD declined as the level increased after 3. Psychotropic drugs were prescribed in 61.5% of those with BPSD. Antipsychotic drugs were used significantly more frequently in those with nursing care resistance, assault and delusions than in others (all, p <0.005). A multivariate analysis showed that the positive predictor of BPSD was antipsychotic drug use, while negative predictors were an LTCI care-need level and the use of visiting rehabilitation. CONCLUSION: The BPSD in elderly dementia patients receiving home medical treatment were clarified. The LTCI care-need level is an independent predictor of BPSD after adjusting for the activities of daily life. Further longitudinal investigations including the BPSD severity and frequency are needed.

Factors associated with changes of care needs level in disabled older adults receiving home medical care: Prospective observational study by Osaka Home Care Registry (OHCARE).

AIM: To clarify factors associated with changes in care needs level and mortality among disabled older people receiving home medical care over a period of 2.5 years. METHODS: The study included 179 participants, aged ≥65 years, receiving home medical care, who consented to join the Osaka Home Care Registry study. The main outcome was changes in the care needs level of participants eligible for the long-term care insurance system. We investigated the association of changes in care needs level with basic characteristics and care-receiving status. RESULTS: At the 2.5-year follow up, 20.0% of participants showed deteriorated levels, and 41.8% of participants died. In multiple logistic regression, age (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.00-1.21; P = 0.051) and bone joint diseases (OR 0.34, CI 0.09-1.22; P = 0.098) were possible risks associated with deterioration of the care needs level. Male sex (OR 3.28, CI 0.91-11.74; P = 0.068) was a possible risk factor for mortality, and lower serum albumin (OR 0.22, CI 0.07-0.73) was a significant risk factor for mortality. CONCLUSIONS: We clarified the different factors associated with deterioration of the care needs level and mortality among disabled older people. Old age and bone joint diseases might be predictive factors for the further deterioration of independence of physical activity, and a low serum albumin level is considered to be strongly associated with increased mortality. Geriatr Gerontol Int 2019; 19: 1198-1205.

Nasal high-flow oxygen therapy system for improving sleep-related hypoventilation in chronic obstructive pulmonary disease: a case report.

INTRODUCTION: Sleep-related hypoventilation should be considered in patients with chronic obstructive pulmonary disease, because appropriate respiratory management during sleep is important for preventing elevation of PaCO2 levels. A nasal high-flow oxygen therapy system using a special nasal cannula can deliver suitably heated and humidified oxygen at up to 60 L/min. Since the oxygen concentration remains a constant independent of minute ventilation, this system is particularly useful in patients with chronic obstructive pulmonary disease who have hypercapnia. This is the first report of sleep-related hypoventilation with chronic obstructive pulmonary disease improving using a nasal high-flow oxygen therapy system. CASE PRESENTATION: We report the case of a 73-year-old Japanese female who started noninvasive positive-pressure ventilation for acute exacerbation of chronic obstructive pulmonary disease and CO2 narcosis due to respiratory infection. Since she became agitated as her level of consciousness improved, she was switched to a nasal high-flow oxygen therapy system. When a repeat polysomnography was performed while using the nasal high-flow oxygen therapy system, the Apnea Hypopnea Index was 3.7 times/h, her mean SpO2 had increased from 89 to 93%, percentage time with SpO2 ≤ 90% had decreased dramatically from 30.8 to 2.5%, and sleep stage 4 was now detected for 38.5 minutes. As these findings indicated marked improvements in sleep-related hypoventilation, nasal high-flow oxygen therapy was continued at home. She has since experienced no recurrences of CO2 narcosis and has been able to continue home treatment. CONCLUSIONS: Use of a nasal high-flow oxygen therapy system proved effective in delivering a prescribed concentration of oxygen from the time of acute exacerbation until returning home in a patient with chronic obstructive pulmonary disease, dementia and sleep-related hypoventilation. The nasal high-flow oxygen therapy system is currently used as a device to administer high concentrations of oxygen in many patients with type I respiratory failure, but may also be useful instead of a Venturi mask in patients like ours with type II respiratory failure, additionally providing some positive end-expiratory pressure.

Positive outcome of average volume-assured pressure support mode of a Respironics V60 Ventilator in acute exacerbation of chronic obstructive pulmonary disease: a case report.

INTRODUCTION: We were able to treat a patient with acute exacerbation of chronic obstructive pulmonary disease who also suffered from sleep-disordered breathing by using the average volume-assured pressure support mode of a Respironics V60 Ventilator (Philips Respironics: United States). This allows a target tidal volume to be set based on automatic changes in inspiratory positive airway pressure. This removed the need to change the noninvasive positive pressure ventilation settings during the day and during sleep. The Respironics V60 Ventilator, in the average volume-assured pressure support mode, was attached to our patient and improved and stabilized his sleep-related hypoventilation by automatically adjusting force to within an acceptable range. CASE PRESENTATION: Our patient was a 74-year-old Japanese man who was hospitalized for treatment due to worsening of dyspnea and hypoxemia. He was diagnosed with acute exacerbation of chronic obstructive pulmonary disease and full-time biphasic positive airway pressure support ventilation was initiated. Our patient was temporarily provided with portable noninvasive positive pressure ventilation at night-time following an improvement in his condition, but his chronic obstructive pulmonary disease again worsened due to the recurrence of a respiratory infection. During the initial exacerbation, his tidal volume was significantly lower during sleep (378.9 ± 72.9mL) than while awake (446.5 ± 63.3mL). A ventilator that allows ventilation to be maintained by automatically adjusting the inspiratory force to within an acceptable range was attached in average volume-assured pressure support mode, improving his sleep-related hypoventilation, which is often associated with the use of the Respironics V60 Ventilator. Polysomnography performed while our patient was on noninvasive positive pressure ventilation revealed obstructive sleep apnea syndrome (apnea-hypopnea index = 14), suggesting that his chronic obstructive pulmonary disease was complicated by obstructive sleep apnea syndrome. CONCLUSION: In cases such as this, in which patients with severe acute respiratory failure requiring full-time noninvasive positive pressure ventilation therapy also show sleep-disordered breathing, different ventilator settings must be used for waking and sleeping. On such occasions, the Respironics V60 Ventilator, which is equipped with an average volume-assured pressure support mode, may be useful in improving gas exchange and may achieve good patient compliance, because that mode allows ventilation to be maintained by automatically adjusting the inspiratory force to within an acceptable range whenever ventilation falls below target levels.

Rapid improvement of massive bloody pleural effusion after splenectomy for splenic marginal zone lymphoma.

Splenic marginal zone lymphoma (SMZL) is a rare malignant lymphoma involving marginal zone B cells, accounting for only 1% of non-Hodgkin lymphomas. No previous reports have documented SMZL accompanied by massive bloody pleural effusion. Herein, the case of a patient with SMZL that was only diagnosed after splenectomy and thoracoscopic pleural biopsy is presented. SMZL in this patient was accompanied by massive bloody pleural effusion. The characteristics of the patient's pleural effusion changed from bloody to transudative after splenectomy, and rapid improvement was observed. It was considered that the splenectomy was valid for treatment of unidentified pleural effusion with enlarged spleen.

Clinical and prognostic importance of serotyping Mycobacterium avium-Mycobacterium intracellulare complex isolates in human immunodeficiency virus-negative patients.

We studied whether the serotypes of Mycobacterium avium-Mycobacterium intracellulare complex (MAC) isolates determine the prognosis for pulmonary MAC disease. We prospectively monitored a cohort of 68 patients with pulmonary MAC disease for whom the serotype-specific glycopeptidolipids in isolates were identified using thin-layer chromatography and fast atom bombardment mass-spectrometry in 1990 and 1995. Serovar 4 Mycobacterium avium was detected in 40/68 patients (58.8%). Other serotypes were serotypes 1 (five cases), 6 (three cases), 8 (seven cases), 9 (three cases), 14 (four cases), and 16 (six cases). Patients with serovar 4 were significantly (P < 0.01) younger (63.0 +/- 9.8 years) than patients with other serotypes (71.8 +/- 10.3). Patients who failed treatment had a significantly poorer prognosis than other patients. There were no cases of MAC-related death in the cured group. Chest radiographic findings progressively worsened in 36 (90%) of patients with serotype 4, and 14/36 died from respiratory failure caused by pulmonary Mycobacterium avium disease. The patients with serotype 4 had a significantly poorer prognosis than patients with other serotypes. These results show that both the outcome of chemotherapy and the serotypes of MAC isolates are important for assessing the prognosis of pulmonary MAC disease.

[Grading of officially acknowledged respiratory disability and exercise disorders using cardiopulmonary exercise testing in patients with chronic respiratory diseases].

This study examines whether the grading of officially acknowledged respiratory disability reflects exercise disorders in patients with chronic respiratory diseases. In order to do this, we analyzed the cardiopulmonary exercise testing (CPET) data of 258 patients with chronic obstructive pulmonary disease (COPD), 125 with sequela of pulmonary tuberculosis (TB) and 52 with interstitial pneumonia between 1989 and 2002. The peak oxygen uptakes of grade 1 and 3 COPD patients were 12.4 +/- 3.8 and 14.9 +/- 4.3 ml/min/kg (mean +/- SD), respectively. The worse the grade, the lower was the peak oxygen uptake, the differences being significant in COPD patients. Despite this, the peak oxygen uptake range overlapped greatly between grade 1 and grade 3 COPD patients. Sixty percent of patients with TB and 46% of patients with IP whose peak oxygen uptakes were similar to those of grade 1 COPD patients failed to be acknowledged as grade 1. There were no significant differences between the peak oxygen uptake of grade 1 COPD patients and grade 1 TB patients, grade 3 TB patients, and grade 4 IP patients. Patients with TB and IP showed more severe ventilatory and gas exchange disorders than those with COPD. We concluded that the present system of acknowledgement of respiratory disability in Japan did not accurately reflect exercise disorders in patients with chronic respiratory diseases. As well as this, we argue that there is discrimination between patients with COPD, TB and IP. It is necessary to establish an alternative system, reflecting exercise disorders evaluated by CPET to offer a more accurate acknowledgement.

Rapid serodiagnosis of active pulmonary Mycobacterium tuberculosis by analysis of results from multiple antigen-specific tests.

We have prospectively analyzed three antigens for serodiagnosis of tuberculosis (TB). These antigens were tuberculous glycolipid antigen, lypoarabinomannan polysaccharide antigen, and antigen 60 (A60), which was derived from purified protein derivatives. Of the 131 patients with active pulmonary TB, 57 were both smear and culture negative and 14 had chronic active pulmonary TB that remained smear positive for >12 months of chemotherapy. One hundred twenty healthy adults were controls. The percentages of patients positive in all three tests were 58.8% for smear-positive active pulmonary TB and 71.4% for chronic active pulmonary TB. When the results of the three serodiagnostic tests were evaluated in combination, the sensitivity increased to 91.5% in patients with active pulmonary TB and to 86.0% in smear- and culture-negative patients. The false-positive rate of the three-test combination was 12.5% in the healthy control groups. In conclusion, it was not possible to detect all of the antibodies against antigenic substances in the cell walls of the tuberculous bacilli in the sera of all TB patients by using available serodiagnostic tests. However, the combined use of tests with three separate antigens maximizes the effectiveness of serodiagnosis.

Prognostic predictors for survival in patients with COPD using cardiopulmonary exercise testing.

We studied the relationship between physiologic parameters in cardiopulmonary exercise testing (CPET) and prognosis in terms of survival time in patients with chronic obstructive pulmonary disease (COPD) in order to accurately assess the severity of the disease. From a group of 195 patients with COPD who had consecutively undergone CPET between July 1989 and October 1997, we enrolled 120 subjects (mean age 67.6 years, 104 males) with exertional dyspnoea into a cohort protocol. Of these subjects, 34 (28.3%) died during the 3-5-year follow-up period after CPET. By univariate analysis, the following factors were significantly associated with survival time: age, body mass index, %FVC, %FEV1, FEV1%, PaCO2 at rest, severity of exercise-induced hypoxemia evaluated by DeltaPaO2/DeltaVO2 (PaO2-slope), oxygen uptake, ventilation, tidal volume, PaCO2 and oxygen pulse at maximum exercise, as well as prescribing long-term oxygen therapy. By multivariate analysis, age and the PaO2-slope showed significance as independent prognostic factors, and the PaO2-slope was most closely associated with the survival time. These results reveal that CPET is a useful technique to accurately assess the relationship between the functional impairments and the prognosis of patients with COPD.

[Long-term care insurance eligibility in Japan for patients having home oxygen therapy].

In Japan, long-term care insurance (LTCI) for the elderly has been available since April 2000. Eligibility levels for LTCI for patients with home oxygen therapy (HOT) was investigated for two periods during a 20-month interval between April 2000 and December 2001. During these periods, we hosted a seminar on respiratory care, taking the form of a special report on the daily life of HOT patients. This report was submitted to an expert committee in order to inform the members of the committee about the characteristics of HOT patients. Of 76 HOT patients who had utilized visiting-nurse services, 58 applied for an assessment for LTCI eligibility. The levels determined were less than those expected by the patients' doctors (Categories: Not fulfilling the criteria, seven cases; Rejected, 13 cases; Assistance-required, six cases; Care-required, level 1, 14 cases; Care-required, level 2, 10 cases; Care-required, level 3, three cases; Care-required, level 4, three cases; and Care-required, level 5, two cases). As many as six of the 27 patients who used home mechanical ventilation were rejected. There were also patients who were forced to stop the care services that they had been receiving. Forty patients, including eight who applied for a re-assessment, were finally assigned to a Care-required category. The home-help service was the most frequently utilized (35.0%). Day services, short stay, and the visiting-bathing service, which are commonly used for patients with cerebral apoplexy sequela, were not needed nearly as much (5.0%, 2.5%, 2.5%, respectively). The eligibility levels at the second point of evaluation were higher than those at the first point in 37.5% of the patients, and equal in 58.3%. In the 39 new-applicant patients at the second point of evaluation, the ratio of Care-required patients was significantly increased (62.7% to 72.2%, p < 0.05). The eligibility level is primarily decided by computer using a score derived from a form that contains 73 questions about the physical condition of the applicant. However, this information is inadequate for a precise assessment of the impairment of the HOT patients. The final decision on a patient is made by an expert committee, based on both the primary result and the report of the doctor in charge of that patient. It may be effective to inform the members involved in the final decision about the characteristics or special needs resulting from the disease that necessitates HOT. However, we believe that it may be more important to find a way to increase the validity of the primary judging. We would argue that a method for proper assessment of HOT patients should be designed.

Exercise-induced electrocardiographic changes in patients with chronic respiratory diseases: differential diagnosis by 99mTc-tetrofosmin SPECT.

UNLABELLED: Evaluation of possible cardiac complications is essential for safe and effective respiratory rehabilitation of patients with chronic respiratory diseases (CRDs). The aim of this study is to clarify the pathophysiology of electrocardiographic (ECG) changes during exercise and the prevalence of coronary artery disease (CAD) in CRD patients without a history of myocardial ischemia. METHODS: We studied 42 CRD patients with exercise-induced ST depression by cardiopulmonary exercise testing (CPET). They were selected from 249 consecutive CRD patients without any history of CAD who underwent CPET between January 1999 and December 2001. Thirty-three patients without respiratory diseases who had positive ST depression during exercise were selected as disease control subjects. Exercise myocardial SPECT was performed to evaluate myocardial ischemia and right ventricular (RV) overload as measured by increased RV uptake. RESULTS: Among the 249 consecutive CRD patients without any history of CAD, positive ST depression during exercise was found in 42 (16.9%). Only 2 of the 42 patients (4.8%) had an ST depression other than in II, III, or aVF leads. The incidence of myocardial ischemia by perfusion SPECT was significantly lower in CRD patients (26.2%) than in disease control subjects (78.8%). The most common finding in the CRD patients during exercise was RV overload but without ischemia (26 cases; 61.9%). Ischemia was found in 11 patients (26.2%), with 10 of these patients also having RV overload. Neither ischemia nor RV overload was found in 5 patients (11.9%); these patients were eventually diagnosed as normal. CONCLUSION: The incidence of myocardial ischemia as determined by perfusion SPECT was low in CRD patients with positive exercise-induced ECG changes. On the other hand, RV overload was observed in most such cases. Cardiac perfusion SPECT is a useful technique to evaluate cardiac ischemia and RV overload simultaneously. CPET with 12-lead ECG monitoring is necessary in CRD patients before respiratory rehabilitation. Further examination for ischemia should be done if positive ST depression is found.

Prospective clinical evaluation of the serologic tuberculous glycolipid test in combination with the nucleic acid amplification test.

We have conducted a prospective controlled multicenter study to evaluate differences in the levels of clinical utility of the tuberculous glycolipid (TBGL) serodiagnostic test and the nucleic acid amplification test in patients with smear-negative active pulmonary tuberculosis (TB). The TBGL test and the PCR test were individually not so useful for the rapid diagnosis of smear-negative active pulmonary TB. However, clinical utility was considerably improved by using the TBGL test and the PCR test in combination, especially in patients with smear-negative and culture-negative active pulmonary TB and in patients with minimally advanced lesions.