Aim: Bullous pemphigoid (BP) is an autoimmune skin disorder characterized by the production of autoantibodies. Several recent reports have described the occurrence of BP in diabetic patients treated with dipeptidyl peptidase-4 (DPP-4) inhibitors. However, the clinical features of BP in diabetic patients, particularly in those treated with DPP-4 inhibitors, have not yet been examined. The aim of this study was to clarify clinical characteristics of BP in elderly type 2 diabetic patients.
Methods: We found cases of BP in 15 elderly type 2 diabetic patients (11 men, 4 women) and 20 non-diabetic patients (8 men, 12 women) from September, 2012 to September, 2016. These patients had all been treated with corticosteroid therapy. We investigated the participants' basic clinical characteristics and the course of BP treatment. The differences in variables between the two groups were analyzed using Wilcoxon's test and the chi-square test.
Results: The mean age of type 2 diabetes patients with BP was 81.1±5.5 years. The mean HbA1c was 7.3±1.6%. A total of 87% of diabetic patients had been treated with DPP-4 inhibitors for 11.7 months prior to the BP onset. The diabetic patients had a lower prevalence of neurogenerative disease, severe ADL disabilities, and dementia than the non-diabetic patients. Furthermore, the diabetic patients with BP tended to be younger and more frequently male than those without diabetes. After stopping the DPP-4 inhibitors, the skin lesions were successfully treated with systemic corticosteroid therapy, and glycemic control was achieved using intensive insulin therapy. DPP-4 inhibitors were used in all cases where the aniti-BP180NC16a antibody showed negative conversion.
Conclusion: BP in patients with type 2 diabetes had different clinical features from that in non-diabetic patients, suggesting an association between BP and the use of DPP-4 inhibitors.
Aim: In home-visiting bathing services (HVBs), a nurse's role is to evaluate the vital signs, judge bathing possibilities and provide treatment before/after bathing. There are no guidelines regarding specific physical criteria for judging the bathing possibility. However, the body condition of HVB users during bathing has not been investigated. Thus, the present study aimed to clarify users' actual conditions and the factors related to the judgment of the possibility of bathing.
Methods: An anonymous self-administered questionnaire survey of HVBs users was conducted by Company-A, which provides HVBs. Six hundred sixty responses were collected (response rate: 40.1%).
We described the conditions of HVB users and used chi-squared tests and logistic regression analyses to confirm the factors, including the certified Long-term Care Insurance (LTCI) care rank, past medical history and physical conditions that were associated with aborted HVB experiences.
Results: The mean age of the care-recipients was 82.1±12.1 and 93.3% of the recipients had severe conditions, including conditions necessitation the use of medical equipment, pressure ulcers, and contracture. The logistic regression analysis showed that the LTCI-certified-care-rank, the presence of pain, and the need for treatment before bathing were significant factors.
Conclusions: This study showed that users of HVBs not only had high LTCI-certified-care ranks, but that they also required pain management and pre-bathing treatment.
Aim: This study aimed to clarify the effectiveness of using the complete lateral position method to treat elderly patients with severe dysphagia.
Methods: We enrolled 47 patients >65 years of age who had been diagnosed with severe dysphagia using a video endoscopic examination of swallowing at Hida City Hospital between February 1, 2015, and October 31, 2017. We collected and analyzed data pertaining to patient characteristics, the onset of aspiration pneumonia, and treatment outcomes.
Results: Although all patients had severe dysphagia, adopting the complete lateral position method enabled 25 patients (53.2%) to safely perform oral ingestion and be discharged home or to a nursing home. Thirteen (52.0%) of the patients who were discharged were able to safely receive oral intake in the sitting position again. In addition, the serum albumin level and Barthel index were significantly improved. In the patients whose condition worsened due to senility, the fasting period in the complete lateral potion group was significantly shorter than in the control group (7.3 days vs. 17.3 days).
Conclusions: The present study showed that the complete lateral position method enabled safe oral ingestion in elderly patients with severe dysphagia. Safe oral ingestion contributed to improved nutrition and rehabilitation. The complete lateral position method is easy to assume and does not require the use of special appliances or techniques. We believe that the complete lateral position method will prove to be a breakthrough approach in the care of elderly patients with severe dysphagia.
An 80-year-old woman who was hospitalized due to small subarachnoid hemorrhaging caused by a bruise in the left temporal region of the brain. Nausea/vomiting and malaise appeared after dinner on the fourth day of the illness. Head computed tomography showed that the post-traumatic status was almost normal; however, the sodium ion (Na+) level was 114 mEq/L, indicating severe hyponatremia. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) following a head injury was initially suspected, and water restriction and saline fluid replacement were initiated. However, the Na+ level did not improve, and signs of dehydration emerged. On the seventh day of the illness, drinking water restriction was discontinued, and 3% sodium chloride fluid replacement was initiated. The patient subsequently followed a favorable course, and the Na+ level remained normal even after fluid replacement was discontinued. It is important to differentiate between SIADH and cerebral salt wasting syndrome (CSWS), as the treatment of the two are diametrically opposite. However, distinguishing between these two diseases at an early onset can be difficult, as they have very similar laboratory findings. CSWS can occur in patients with minor head injury, as in the present case, so we should bear this disease in mind as a differential diagnosis, even when imperceptible graduations are recognized in patients.
An 85-year-old woman hospitalized for rehabilitation after cerebral infarction developed persistent bloody diarrhea and was transferred to our hospital (day 1). Contrast-enhanced computed tomography of the abdomen showed edematous thickening extending from the left side of the transverse colon to the rectum, with decreased mucosal enhancement. She was diagnosed with ischemic enteritis. She fasted and was treated with fluids and antibiotics. The bloody diarrhea stopped, and she was restarted on the direct oral anticoagulant (DOAC) edoxaban on day 5. Endoscopy on day 11 showed linear ulceration and severe mucosal edema in the rectum. The diarrhea was persistent, so fasting and fluid therapy were continued. A blood test on day 18 showed significant prolongation of the prothrombin time (≥100 s), International Normalized Ratio (14.03), and activated partial thromboplastin time (87.5 s), as well as a significant increase in protein induced by vitamin K absence-II (12,469 mAU/mL). Her condition was diagnosed as a coagulation abnormality due to vitamin-K deficiency. A vitamin-K preparation was administered immediately, and her coagulation abnormality improved rapidly. In general, DOACs do not require routine monitoring with blood tests. However, frequent monitoring of the coagulation function is required in fasting patients on DOACs because acute coagulation abnormalities can be induced rapidly by vitamin-K deficiency. Given that non-valvular atrial fibrillation and ischemic enteritis are among the most prevalent diseases affecting older people, the likelihood of encountering these diseases in daily clinical practice will increase with the aging of the population. We herein report this instructive case suggesting that a severe coagulation abnormality may develop during treatment for ischemic enteritis in older people taking a DOAC.