Factors related to home discharge of cerebrovascular disease patients: 1-year follow-up interview survey of caregivers of hospitalized patients in 53 acute care hospitals in Japan.

In Japan, many disabled elderly people remain hospitalized for long periods. Cerebrovascular diseases (CVD) are the most causes responsible for such disability. To examine the predictors of home discharge in CVD patients, we performed a 1-year follow-up interview of the main caregivers of patients hospitalized with a CVD event. The initial cohort consisted of CVD patients hospitalized in all the second level emergency and general hospitals in Ibaraki Prefecture in February 1992 (N=888 patients in 53 hospitals). In the following year, we performed an interview survey of the main caregivers of these CVD patients. The survey items included the characteristics of the patients (including medical and socioeconomic conditions), caregivers, and family members. The final study population included the main caregivers of 187 home patients and 90 institutionalized patients. We compared these two groups in terms of predictors of discharge to home. The results of multiple logistic regression analysis showed that the following seven factors were related to home discharge; better baseline activities of daily living (ADL), larger improvement in ADL, larger family size, spouse as the caregiver, caregiver without a full-time job, better economic status of the caregiver, and sources of the patient's income. Our study indicated that the caregiver's conditions were closely related to home discharge of the CVD patients. More attention should, therefore, be centered on the caregiver's well-being and economic aspects as well as the patient's conditions in order to encourage home discharge of stroke patients.

[Outcome based quality-improvement methods in visiting nursing services (VNS) in Japan: practical report and feasibility].

For the execution of the nation's public long-term care insurance in the year 2000, and Quality Improvement (QI) of visiting nursing services (VNS) will become extremely important in Japan. Some standard methods to evaluate structure or process in VNS have been published but there is no report of actual QI performance based on outcome measurement in each VNS institution. Modifying the method introduced by JCHO in USA, we performed QI using one negative outcome "unexpected cessation of home care" as a monitoring outcome measurement. In three VNS institutions variously located in Japan, cases of unexpected-cessation in one year were monitored retrospectively, then blindly assessed by nurses. Cases were categorized into "avoidable cessation" or "unavoidable unexpected-cessation", and for the "avoidable" cases the kinds of improvement that would be necessary to avoid this type of unexpected-cessation in the future were discussed. Depending on the situation of the facility, some of the suggested improvements were executed within possible ranges. The numbers of unexpected-cessation of home health care in each institution were 89, 58 and 15 with incidences from all the cases in one year of 46%, 40% and 42% respectively. In these cases, 47, 39 and 15 cases were categorized as "avoidable". Generally, improper nursing assessment in changes of patients' physical condition was the biggest cause of home health care unexpected-cessation. Although some institution were not able to accomplish any part, each institution were able to capture their unique problems and made a detailed specific QI plan to avoid cessation of home care in the future. The two main problems in feasibility were "the analysis took too long (8-9 hours)" and "part-time staff member could not participate". This simple modified QI method provides useful Quality Improvement of Japanese VNS with a limited staff. However, to facilitate execution, a much fairer recognition of the importance of QI, computerization or the partial consignment to a third party, and investigation over a shorter period were considered to be effective.

[Teaching hygiene and public health with student facilitators an attempt to enhance student participation].

In order to enhance student participation in lectures of hygiene and public health, we introduced a student facilitator (SF) system into the lectures of the fourth grade medical students. All students were assigned to one of the 28 classes as SF, thus each class had 4 to 5 SFs. A few weeks before the lecture, each teacher gave SFs various instructions to prepare for the class depending on the theme and teaching strategies. Some classes consisted of dialogues between the teacher and SFs in other classes gave presentations related to the theme of the lecture. For example, SFs in a class of epidemiology performed a small epidemiological survey using their fellow students as study subjects, thus allowing students to learn epidemiological design and calculation of odds ratios. In a class of care management, SFs played roles of caregiver, family member, social worker, physician, etc., showing how actual care management is conducted. The evaluation survey for the SF system showed that in general, students rated the SF system positively, especially at the time they served as SFs. Most of the students showed more interest in the subjects and felt more confident about what they learned as compared to ordinary classes. This finding is important because, previously, the largest problem with the lectures of hygiene and public health used to be the poor interest of students in the subject itself. On the other hand, students sometimes complained about the poor quality of the presentation by SFs. Also, a few students sometimes felt that for obtaining the large volume of knowledge required by the national board examination for medical practice, the SF system was inefficient. In summary, the SF system has some advantage in evoking interests in learning hygiene and public health with sufficient systematic preparation. However, it may not be an efficient way to simply obtain large amounts of knowledge. To improve the SF system, well designed teaching strategies in addition to a carefully prepared textbook are essential.

Correlation between UVB irradiation and the proportion of cataract--an epidemiological study based on a nationwide patient survey in Japan.

Among the multiple factors affecting the human eye in work environment, ultraviolet B irradiation (UVB) has received much attention recently. To provide a clear information for the association between cataract and UVB irradiation, the prevalence data from the Patient Survey and UVB estimates in all the 47 prefectures in Japan were used to examine the relationship between cataract and UVB. In analyzing the relationship, we controlled possible effect modifiers; which were aged, that is 65 years old (yo.) or older, population per ophthalmologist, proportions of all the patients among the aged population and proportion of very elderly population (75 yo. or older) among the aged population. A sex-specific logistic regression analysis revealed that the adjusted odds ratio in women was 1.118 with a 95% confidence interval of 1.058-1.183. However, the adjusted odds ratio in men was not statistically significant (1.048 with 95% confidence interval 0.968-1.135). The unstable results of this study may be largely due to the non-definitive estimation of UVB exposure that this kind of study should be repeated when more valid UVB estimates is available.

[Simulation exercises, a problem oriented method of learning public health in medical education].

Using the case method of learning of American business schools, we introduced "Simulation Exercises (SE)," a problem oriented method of public health education for medical students. With SE, a group of students were given simulated cases of patients or situations (SC), and were asked to assume the role of physicians or other public health workers using their skills and knowledge of public health. Students learn on their own, with the aid of tutors, through discussion, role-play, investigation of literature, and a small field survey. There have been a whole variety of SC covering most of the current topics in public health ranging from mental health, dental health, industrial health, maternal & child health, elderly care, terminal care and international health. Each SC has 5 to 10 questions which stimulate and direct the students' group discussion. Some of the questions do not have a correct answer, but the criteria used to evaluate the students included clarity, consistency, and comprehensiveness of their ideas in addition to the positive commitment to the group discussion. At the end of the week-long group learning, each group demonstrated the results of their discussion. Role play was often used to demonstrate what they learned. As a result, students participated positively and concentrated and enjoyed the learning exercise very much. An anonymous survey shortly after SE showed that more than 80% of students felt a positive change in their rating of public health among the many subjects of study. Tutors also changed their rating of the students after observing their positive attitude and sometimes very creative ideas. In conclusion, we found SE to be useful for practical learning by medical students of public health.

The role of geriatric intermediate care facilities in long-term care for the elderly in Japan.

Geriatric intermediate care facilities (GICFs) were first established in 1987 to help the hospitalized elderly return home within 3 months. Users of the GICFs are the elders who do not require hospitalization, but are mentally or physically impaired. Rather than providing unnecessary medical services, GICFs emphasize nursing care and rehabilitation so that users can carry out their daily tasks independently. Due to the limited supply of institutional and in-home services for the elderly in long-term care systems in Japan, only half of the discharged users were able to return home and a quarter stayed at GICFs for over 1 year, contrary to the initial purpose. This suggests that in addition to serving as an intermediate facility between institutions and private homes, GICFs should enlarge their role of home care supporting facilities in ways that would enable them to provide frail elderly patients at home with respite care and daycare services.

Characterization of the purified cytosolic thymidine kinase from murine ehrlich ascites tumor: interconversion of two different relative molecular weight forms.

Cytosolic thymidine kinase was purified 18,000-fold of the homogenate from murine Ehrlich ascites tumor, using the [p-aminophenyl 3' -dTMP]-CH-Sepharose affinity column. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the purified enzyme showed a single protein band of molecular weight 26,000. Two different forms, relative molecular weight 50,000 and 70,000, were found by gel filtration, depending on the existence of dithiothreitol, ATP and other nucleotides. These agents also stabilize and stimulate the enzyme activity. The existence of two forms was also manifested by DEAE-Sephacel column chromatography, where the 50,000 form was eluted by 50 mM NaCl and the 70,000 form by 400 mM NaCl.

Gender difference in the utilization and users' characteristics of community rehabilitation programs for cerebrovascular disease patients in Japan.

The purpose of this study was to see whether there was gender difference in the utilization of a community rehabilitation program for cerebrovascular disease (CVD) patients in Japan and to examine factors affecting this gender difference. For CVD patients who participated in 16 community rehabilitation programs in the Saitama prefecture (n = 190), we studied their clinical and functional status, socioeconomic conditions, the degree of family support, and their use of rehabilitation and transportation services. The general characteristics of the programs and the type of transportation services they offered were also surveyed. The female proportion of all the program participants was 34.2% and its proportion tended to be smaller when their ADL level was worse. However, such difference by gender lessened after the participants were stratified by the type of transportation services and by such conditions as being accompanied by a family member during transportation.

[Factors affecting ADL improvement and QOL in stroke patients a community-based study].

To clarify the factors affecting improvement of activities of daily living (ADL) and quality of life (QOL) in stroke patients, 141 patients and their families attending municipal rehabilitation programs in Saitama Prefecture were surveyed by means of self-rating questionnaires and interviews. Subjects had attended the rehabilitation programs for 0-16 (mean 3.2) years. The patients were divided into two groups, i.e., ADL-improved and ADL-unimproved, according to Katz scale scores before and after their rehabilitation. Results of the multiple logistic regression analysis indicated that initial ADL before attending the rehabilitation programs and a short time interval between disease onset and start of rehabilitation are major factors for the improvement of ADL. Similarly, old age, high ADL, official certification of disability, and low frequency of rehabilitation were significant factors for high QOL as measured by Philadelphia Geriatric Center morale scale (stepwise multiple regression analysis). It is suggested that municipal rehabilitation programs pay special attention not only to accessibility of low-ADL patients, but also to psychological factors of young patients with low ADL, high frequency of attendance at rehabilitation programs and no official certification of disability.

Nodular pulmonary amyloidosis associated with asbestos exposure.

A 71 year old man was admitted for the purpose of diagnosis of a right solitary pulmonary nodule. The size of the nodule was 18 x 18 mm in diameter 2 years ago, but it has become large, 25 x 25 mm in diameter. The nodule was resected by thoracotomy. Microscopically, eosinophilic amorphous, acellular substances were surrounded by inflammatory infiltrates. It stained with Congo red stain and showed green birefringence with polarizing microscopy. Amyloid fibrils were observed electron microscopically. Asbestos bodies were observed in the lung parenchyma around the nodule. This case shows that a nodule in nodular pulmonary amyloidosis can grow gradually and suggests the possibility of asbestos fibers as one of the etiologic factors in nodular pulmonary amyloidosis.

[Yearly changes and geographical distribution of allergic rhinitis morbidity estimated from records of the national health insurance].

The age-adjusted morbidity of allergic rhinitis (AR) in Ibaraki prefecture in May, estimated from data of national health insurance records, increased remarkably from 1980 to 1992 with varying yearly rates of increase. High AR morbidity years coincided with years of high Japanese cedar and cypress pollen counts, and moreover, an estimate equation of the morbidity using as explanatory variables, year and the yearly total count of pollen, accurately estimated AR morbidity. The AR morbidity varied with the size of the municipality. The AR morbidity of the town group and village group were about 80% and about 60% respectively of the city group in 1992. The map of the AR morbidity of each municipality showed that urbanized districts had higher morbidity than areas with cedar forests, which are supposedly sources of the cedar pollen. Continuous increase of morbidity of districts with much cedar forests terminated in 1986. Since then only the fluctuation of the morbidity corresponding to the pollen count was observed. The ratio of the morbidity of the years with much pollen to that of the years with little pollen was mapped. The map showed good agreement with the map of cedar forests. The results obtained above demonstrate the usefulness of the data of the national health insurance records.

Tertiary structure of erabutoxin b in aqueous solution as elucidated by two-dimensional nuclear magnetic resonance.

The three-dimensional structure of erabutoxin b, a short-chain neurotoxic peptide purified from the venom of the sea snake Laticauda semifasciata, was determined in aqueous solution by two-dimensional proton nuclear magnetic resonance and simulated annealing-based calculations. On the basis of 883 assigned nuclear Overhauser effect (NOE) connectivities, 676 final distance constraints were derived and used together with 38 torsion angle (phi, chi 1) constraints, four distance constraints derived from disulfide bridges and 30 distance constraints derived from hydrogen bonds. A total of 14 converged structures were obtained from 50 runs of calculations. The atomic root-mean-square difference about the mean coordinate positions (excluding the residues 18 to 22) is 0.60 A for backbone atoms (N, C alpha and C'). The protein consists of a core region from which three finger-like loops emerge outwards. It includes a short, two-stranded antiparallel beta-sheet of residues 2 to 5 and 13 to 16, a three-stranded antiparallel beta-sheet involving residues 23 to 30, 35 to 41 and 50 to 56, and four disulfide bridges in the core region. Comparison with two crystal structures of erabutoxin b at 1.4 A and 1.7 A resolution indicated that the solution and the crystal structures were very similar, but less defined regions were observed at the localized region of the tip of the central loop and the outside of the third loop in solution. Other short-chain alpha-neurotoxins showed structural characteristics similar to those of erabutoxin b.

[A study of thymidine kinase activity in lung cancer tissue].

In order to investigate the usefulness of thymidine kinase, which acts to salvage thymidine to its nucleotide for DNA biosynthesis, as a marker of malignancy in lung cancer, the enzyme activities in extracts of tumors and uninvolved lungs of 83 resected cases of lung cancer were determined. The mean value of thymidine kinase activity in tumors was as much as 4.3 times higher than that of uninvolved lungs. There was no significant correlation between the activity in tumors and clinicopathological findings such as histological type, the grade of histological differentiation, pT factor, pN factor, pTNM stage and tumor size. The tumor doubling time did, however, show a significant inverse correlation with activity when compared logarithmically (r = 0.879, p = 0.00002). Moreover, there was a significant relationship between enzyme activity and post-operative recurrence of lung cancer. In conclusion, thymidine kinase was found to be a useful marker of malignancy in lung cancer.

[Study of physical fitness in children, and its application to pediatric clinics and sports medicine].

To estimate the physical fitness of children, the easy and useful method for the measurement of aerobic power was developed. The method was applied to an exercise test and a therapy for obesity. Anaerobic power was also measured, and the development of the physical fitness in children was characterized according to aerobic and anaerobic capacity. Furthermore, the problems in pediatric sport medicine and the influence of sports activity were studied for the management and promotion of health in children. 1. Normal value of VO2max and PWC, parameters of aerobic capacity, were established using a bicycle ergometer adapted to children. In 112 healthy children aged 6-15 years, VO2 max/kg were boys; 62.3 +/- 12.6 ml/kg/min (m +/- SD), girls; 53.8 +/- 12.8 and PWC75%HRmax were boys; 2.39 +/- 0.55 Watt/kg, girls; 1.90 +/- 0.48. Both data were remarkably higher than in adults. 2. An exercise test measuring with aerobic power was established, and cardiovascular responses were analyzed. The test was applied to the medical check for children with periodic sports performance and who had chronic illness. 3. Aerobic power was measured in 22 obese children aged 6-14 years. VO2max/kg and PWC75%HRmax were significantly lower than the normal values. Then, an exercise system was designed for the therapy of obese children, and a good response was obtained in all children. 4. Anaerobic power was also measured using a bicycle ergometer following force-velocity test. In 22 healthy children aged 7-15 years, the peak power was 5-7 Watt/kg which was lower than in adults (9-11 Watt/kg). 5. Daily activity was evaluated by a pedometer and a heart rate monitor. Children tended to become more active as they grew older before the elementary school age, but their activity gradually decreased after that. 6. The problems in pediatric sport medicine were that they tended to exercise not in daily playing but in belonged sport club, and also tended to do sports for winning. It is desirable that children do various kinds of sports using an aerobic power to develop the physical fitness, to have fun and to raise sociality.

Tryptophan residues of phospholipase A2 from the venom of an Australian elapid snake (Pseudechis australis).

Tryptophan residues 31 and 69 (Trp-31 and Trp-69) in phospholipase A2 (Pa-11) from the venom of an Australian elapid snake, Pseudechis australis, were modified with N-bromosuccinimide (NBS) or with 2-nitrophenylsulphenylchloride (NPSC1). NBS oxidized only Trp-31, whereas NPSC1 reacted with both Trp-31 and Trp-69. Treatment of the enzyme with NBS at various pH values resulted in losses of enzymic and lethal activities. No protective effect on the oxidation with NBS was observed by the addition of calcium ion (20 mM) or lecithin (4 mM). The observations suggest that Trp-31 is exposed to the surface of the molecule, composes a part of the lipid-water interface recognition site around the active site and is essential for enzymic activity. Calcium ion addition to the solution caused a change in ultraviolet spectrum of the native enzyme Pa-11. The difference spectrum indicates that a charge effect caused a typical tryptophan blue shift in the Ca(2+)-enzyme complex. Pa-11 oxidized with NBS showed a smaller ultraviolet absorption difference on the addition of Ca2+ ion. The results show that the hypochromic effect induced upon the binding of Ca2+ is due to perturbation of the specific tryptophan residue (Trp-31) which is involved in the active site. Dissociation constant, Kd, of the Ca(2+)-enzyme complex was calculated to be 3.4 x 10(-4) M at pH 8.0.

Studies on the venom components of the long-glanded coral snake, Maticora bivirgata.

The venom of the Asian long-glanded coral snake, Maticora bivirgata, was fractionated into five fractions, S1-S5, by passing through a Sephadex G-50 column. Fraction S2 contains two phospholipases A2, PLA2 I and PLA2 II, fraction S3 contains four cytotoxin homologues, maticotoxins A, C, D1 and D2, and fractions S4 and S5 contain a large amount (about 1 mg/specimen) of adenosine accompanied with smaller amounts of inosine and guanosine. The amino-terminal amino acid sequences of PLA2, I, PLA2 II and maticotoxin A suggest that Maticora bivirgata is closely related to Bungarinae, especially to genera Hemachatus and Naja.

[Factors affecting activity of daily living (ADL) in stroke patients at home].

To examine the effects of housing conditions, health care, age, functional status and other demographic factors on the Activity of Daily Living (ADL), an interview survey of the caregivers of 68 cerebral stroke patients was performed. All patients received care at home for 6-128 (mean 40) months after discharge from hospitals and were 56-91 (mean 79) years old at the time of the survey. During the home care, ADL improved in 28 patients (improved ADL group), and did not change or deteriorated in 26 patients (unchanged/deteriorated ADL group). Three variables, i.e. reconstruction of bathroom (bathing facility and not toilet) in the patient's house after starting the home care, the patient whose main caregiver was his or her spouse, and consultation with a physician at a hospital (not a clinic), were significantly more frequent in the improved ADL group than in the unchanged/deteriorated ADL group. Similarly, the ADL level at the start of home care and age at the time of survey were significantly lower in the improved ADL group. The results of multiple logistic regression analysis indicates that the level of ADL when home care was started (p less than 0.01) and reconstruction of the bathroom (p less than 0.05) were major factors affecting the improvement in ADL.

[Limited operation of carcinoma of the lung].

A clinical study on 207 patients was performed to evaluate partial or wedge resection for lung carcinoma in our institute. Although forced vital capacity decreased 300 ml in cases with poor lung function, blood gas analysis and performance status showed no change due to limited operation. Relative non-curative cases undergoing limited operation showed a relatively good result compared to standard lobectomy, and the 5-year survival rate was 42% postoperatively, but absolute non-curative cases showed a much poorer postoperative prognosis. Reduction surgery by limited operation did not have significant effect on the survival of the patients. Limited operation for recurrent lung cancer showed good results and 5-year survival was 60% postoperatively. It was suggested that limited operation for such selected patients can be a beneficial therapeutic modality. In conclusion, limited resection is not indicated for peripheral lung cancers of more than 3 cm in diameter, poor differentiation or marked cell atypia, because of higher incidence of lymph node metastasis and early postoperative recurrence, especially in adenocarcinoma.

[Factors affecting death at home in bedridden elderly people].

To examine factors which affect death at home in bedridden elderly people, relatives of bedridden elderly people, in three areas of Japan, who had died, were interviewed, and demographic, medical, social and familial factors were compared between 136 persons who died at home and 132 persons who died in the hospital. 1) In all three geographical areas, significantly more subjects who died at home had physicians who made home visits than in those who died at hospital (p less than 0.01). 2) The mean age at death was significantly higher in the elderly people who died at home than in those who died in the hospital in all three areas (p less than 0.01). 3) The results of multiple logistic regression analysis indicated that physician's home visits and death age were significantly related independently to death at home. This relation was independent of confounding factors such as residential area, disease type, or use of social services.