Palliative Care Research Vol. 12(2017) No. 2

Background/Aim: There is almost no study on direct oral anticoagulant (DOAC) for the treatment of venous thromboembolism (VTE) in Japanese patients with advanced cancer. The aim of this study was to evaluate the efficacy of DOAC for the treatment of VTE in Japanese patients with advanced cancer. Methods: We retrospectively reviewed patients with active cancer who had new-onset proximal deep vein thrombosis and/or pulmonary embolism at our hospital. We compared two DOACs, edoxaban and apixaban, with warfarin and evaluated the incidence of VTE recurrence and bleeding in a period of 3 months. The recurrence was diagnosed based on computed tomography or echography findings. Results: The number of patients treated with edoxaban, apixaban, and warfarin was 47, 31, and 30, respectively. In the warfarin group, the mean international normalized ratio of prothrombin time (2SD) after 3 months was 2.11 (0.42). There was no incidence of major bleeding. Non-major bleeding occurred in 17%, 10%, and 27% of the patients treated with edoxaban, apixaban, and warfarin, respectively (edoxaban vs. warfarin, risk ratio [RR]: 0.64, 95% confidence interval [CI]: 0.27–1.52; apixaban vs. warfarin, RR: 0.38, 95% CI: 0.11–1.28). All bleeding episodes occurred in 30%, 26%, 57% of patients treated with edoxaban, apixaban, and warfarin, respectively (edoxaban vs. warfarin, RR: 0.53, 95% CI: 0.31–0.90; apixaban vs. warfarin, RR: 0.46, 95% CI: 0.23–0.89). Recurrent VTE in edoxaban, apixaban, and warfarin groups occurred in 8%, 3%, and 16% of the patients, respectively (edoxaban vs. warfarin, RR: 0.52, 95% CI: 0.18–2.18; apixaban vs. warfarin, RR: 0.22, 95% CI: 0.03–1.80). Fisher’s exact test was used for statistical analysis. Conclusion: Our study suggests that the DOAC groups are relatively at a lower risk of VTE recurrence, non-major bleeding, as well as all bleeding episodes, as compared with the warfarin group. Therefore, DOAC might be useful in the treatment of VTE in Japanese patients with advanced cancer.

Purpose: This study intended to clarify the lesson topics, lesson content and emotions that painfully saddened nursing students with experience of bereavement taking lectures on palliative care, as well as the emotional changes of these students and the support they expect from teachers. Methods: We conducted semi-structured interviews. Their emotions were analyzed following Krippendorff’s method. Results: Thirty-six nursing students participated in the study. Lesson topics and content included “the state and signs of loved ones near death,” and “general lessons.” Feelings and thoughts presented were “regret,” “remembering,” “emotional upset,” “feeling anxiety,” “feeling dissatisfied,” “experiencing a sense of discomfort”, and “empathizing with the people shown in the teaching material as well as their situations.” With the exception of one subject, all subjects experienced a positive change in their emotions. Regarding to the support, 20 people did not require additional support because of “nothing wrong” or “enough”. Conclusions: Teachers need to specifically explain support content and methods many times, and to face lessons with the strong desire to always support their students.

The aims of this study were to clarify difficulties experienced by families facing the cessation of home-based care for terminal cancer patients, and to review the associated necessary nursing practices. We conducted semi-structured interviews with ten families. A qualitative research design was selected for this study, and the data was interpreted using content analysis techniques. The results were integrated into seven major categories: “unable to assess present symptoms for lack of understanding terminal cancer symptoms,” “feeling emotional pain during the patient’s aggravated condition,” “difficulties in coping with various patients’ physical symptoms: problems regarding inexperienced care,” “exhausted by living 24 hours a day with patient: lack of support, because of constraints from important people in the caregiver’s life,” and “difficulties faced by primary family caregivers in preparing a treatment environment.” Family caregivers were not able to prepare a treatment environment, because of a lack of understanding the symptoms of terminal cancer and an unwillingness to admit experiencing mental and physical burdens. The findings of this study suggested that the role of a nurse is to understand the family’s condition and values, provide required information in advance, and to adjust and prepare the treatment environment.

Cancer cachexia is a multifactorial syndrome defined by ongoing loss of skeletal muscle mass that cannot be fully reversed by conventional nutritional support. Nutritional treatment is a component of nutritional support, as well as symptom palliation and nutritional counseling. Nutritional treatment, exercise, and pharmacological agents are essential for treating cancer cachexia. In our studies at palliative care units, 76% and 73% of advanced cancer patients and bereaved families, respectively, required nutritional support, and nutritional support was also found to have beneficial effects on selected groups of advanced cancer patients. Our studies also indicated that as chronic inflammation is the underlying cause of cancer cachexia the plasma C-reactive protein (CRP) level might be useful as a prognostic marker/biomarker of advanced cancer. It was suggested that nutritional support based on the mechanism responsible for cancer cachexia is useful during the treatment of cancer cachexia although the evidence for this is not robust, and the CRP level is suggested to be a clinically significant index of the response to such treatment.

Bradycardia or asystole during epileptic seizure are referred to as ictal bradycardia syndrome. Ictal asystole is very rare, and there is no report about ictal bradycardia syndrome caused by brain metastases. A 62-year old man was diagnosed as having lung cancer and had multiple brain metastases. The patient had no history of epilepsy and syncope. The patient developed cardiac asystole with sinus arrest for up to 16 seconds. The bradycardia was associated with other signs and symptoms, including abdominal pain, nausea, low blood pressure, sinus arrest, decreased level of consciousness, and staring at a single point. Electroencephalograms showed multiple sharp waves. Repeated seizures, ictal asystole, and coexisting symptoms disappeared after improved treatment of brain metastases by radiation therapy. Therefore, a diagnosis of ictal asystole caused by brain metastases was made. There is no recommended treatment for ictal bradycardia syndrome. However, in the case of ictal bradycardia syndrome caused by brain metastases, treatment of the metastatic tumor might be useful. When patients with cancer present with syncope or sick sinus syndrome, we should consider the possibility of cardiac arrest caused by an epileptic seizure.

Introduction: We are reporting on our experience with a case involving chronic diarrhea that had been continuing for 14 years following anticancer treatment, in which diarrhea and the nutritional status of the patient were unintentionally improved by administered antihistamine. Subject: A 48-year-old female. Fourteen years ago, surgery, chemotherapy, and total pelvic radiotherapy were carried out for cervical cancer, immediately after which diarrhea continued. A laparotomy was performed 11 years ago for Ileus, and radiation enterocolitis was diagnosed upon pathological examination 8 years ago. One month ago, she experienced swelling of the lower limbs after acute cellulitis and visited our outpatient palliative care. Leaking edema due to low nutrition remained following the remission of lymphedema. Ten days prior to re-examination, a maximum dosage of 20 mg/day of olopatadine was prescribed by another department against urticaria, and at the same time, remission of her diarrhea was observed. Oral administration of folic acid and vitamin was completed by continuing small doses, leading to a rise in CK and disappearance of the edema. Discussion: It may be believed that chronic diarrhea was relieved by olopatadine administered for another purpose due to the inhibitory action of 5-hydroxytryptamine 2A receptor, which is a subfamily of serotinin having histamine 1 inhibitory action and the action to increase the bowel movements.

Background: There is increasing demand for clinical clerkships in palliative medicine, though conventional medical education has focused only on providing students with sufficient medical knowledge and skills. In Japan, there is no standard program for palliative medicine in undergraduate medical education. Our hospice, in cooperation with a clinical clerkship for palliative medicine launched by Tokyo Medical and Dental University, has developed its own comprehensive bedside learning curriculum. Aim: This study aimed to evaluate the efficacy of the program. Methods: The curriculum involves not only experience in hospice care, ward rounds, and interviews with terminally ill patients, it also provides each medical student with educational sessions moderated by certified hospice nurses and pharmacists. We conducted a self-administered five-point scale questionnaire (with a higher score indicating higher satisfaction) to assess students’ satisfaction and understanding of the program. We also conducted a questionnaire on basic palliative medicine knowledge before and after the program. Results: Twenty students took part in the program. Ratios of scores of 4 or 5 for satisfaction and understanding of the program were 100% and 95%, respectively. Mean rates of correct answers on the pre-program and post-program test were 51% and 85%, respectively; showing a marked increase and emphasizing the educational significance of our curriculum. Students evidently benefit from the experience of bedside learning, and 95% reported having recommended the program to their juniors. Conclusion: These outcomes suggest the program is effective toward developing a standard education program in palliative medicine.