Attitudes and Other Factors Influencing End-of-Life Discussion by Physicians, Nurses, and Care Staff: A Nationwide Survey in Japan

Context:Better understanding about the attitudes of health-care providers toward end-of-life discussion would facilitate the development of systematic strategies for improving end-of-life care.Objective:To clarify attitudes toward end-of-life discussion with patients near death and explore the factors influencing these attitudes among physicians, nurses, and care staff.Methods:This study was part of a nationwide cross-sectional anonymous survey of the public attitudes toward end-of-life medical care performed in December 2017. The participants were physicians, nurses, and care staff from randomly selected facilities, including hospitals, clinics, home-visit nursing offices, nursing homes, and long-term care facilities throughout Japan. The questionnaire was sent to 4500 physicians, 6000 nurses, and 2000 care staff. We assessed attitudes about end-of-life discussion with patients near death, identification of the proxy decision maker, and sharing documented information on end-of-life discussion with the multidisciplinary team.Results:We analyzed responses from 1012 physicians, 1824 nurses, and 749 care staff. The number of responders who considered they had adequate end-of-life discussion with patients near death was 281 (27.8%), 324 (17.8%), and 139 (18.6%), respectively. Participation in a nationwide education program and caring for at least 1 dying patient per month were factors that showed a significant association with adequate end-of-life discussion and identification of the proxy decision maker.Conclusions:The percentages of physicians, nurses, and care staff involved in adequate end-of-life discussion with patients near death were not high. Participation in a structured education program might have a positive influence on end-of-life discussion with patients

A Report of Four Cases of Intestinal Endometriosis

Four cases of intestinal endometriosis seen at our hospital are presented. The patients ranged in age from 35 to 43 years and developed abdominal pain, vomiting, and dyschezia due to stenotic lesions of the intestine. The sites of the lesions were the ileum in 2 cases, and the sigmoid colon and rectum in 1 case each. All cases had no history of bowel disease or laparotomy, and were not diagnosed preoperatively. These results suggested that evaluations of symptoms and clinical examinations are inadequate for an accurate diagnosis of intestinal endometriosis. The patients’ postoperative courses were uneventful, and there have been no recurrences. In conclusion, intestinal endometriosis should be considered in women of childbearing age who present with bowel obstruction, especially in women without a history of laparotomy

Involvement of vascular endothelial growth factor in nasal obstruction in patients with nasal allergy

It has recently been shown that vascular endothelial growth factor (VEGF) enhances vascular permeability and that mast cells produce VEGF, suggesting the involvement of VEGF in allergic diseases. In the present study we quantitatively analyzed VEGF in the nasal lavage fluid of patients with nasal allergy. We performed nasal antigen challenge with Japanese cedar pollen antigen in 10 healthy adult volunteers and in 10 cedar pollen IgE-positive patients with nasal allergy. In all patients with nasal allergy, VEGF and histamine levels in the nasal lavage fluid reached a peak 30 min after antigen challenge, then returned to prechallenge values 2 h after antigen challenge. In these patients, the histamine level increased three-fold, while the VEGF level increased 10-fold. However, in all healthy adult volunteers, VEGF and histamine levels did not increase. A stronger correlation was noted between the ratio of decreased nasal cavity volume and the ratio of increased VEGF levels (R = 0.823; P < 0.001) than between the ratio of nasal cavity volume and the ratio of increased histamine levels (R = 0.660; P < 0.01). These results suggest that VEGF may contribute to the pathogenesis of nasal obstruction in the early phase of nasal allergy as a new factor involved in increasing vascular permeability

Ten Cases of Colovesical Fistula due to Sigmoid Diverticulitis

Colovesical fistula (CVF) resulting from colon diverticulosis is a comparatively rare disease, and neither the diagnosis nor treatment has been established. Our experience with CVF due to sigmoid diverticulitis over a 9-year period was reviewed to clarify the clinical presentation and diagnostic confirmation. Ten patients with CVF were identified in this period, and chief complaints, laboratory findings, presenting symptoms, diagnostic investigations, and subsequent treatments were reviewed. Preoperative urinalysis showing bacteriuria (100%) was the most common presentation, followed by fecaluria (40%), abdominal pain (40%), pneumaturia (30%), hematuria (30%), pain on urination (30%), pollakiuria (10%), and dysuria (10%). The abilities of various preoperative investigations to identify CVF were: computed tomography (CT), 88.9%; magnetic resonance imaging, 40%; cystoscopy, 30%, and gastrografin irrigoscopy, 22.2%. Colonoscopy (0%) was not diagnostic. Bowel resection was performed in nine of ten patients. When inflammation was intense, covering ileostomy was performed, and an omental plasty was placed between the bowel anastomosis and bladder. When CVF is suspected, we recommend CT followed by colonoscopy and cystoscopy as a first-line investigation to rule out malignancy as a cause. Other modalities should only be used if the diagnosis is in doubt or additional information is needed to plan operative management. Primary colic anastomosis appears to be safely performed by applying omental plasty and covering ileostomy