Purpose: This study is aimed at the evaluation of the effectiveness and safety of gabapentin for the management of cancer-related neuropathic pain in terminally-ill cancer patients. Methods: We investigated terminally-ill cancer patients prescribed gabapentin for the management of cancer-related neuropathic pain, from November 200X to October 200X+2. We assessed average daily pain on the numerical rating scale (NRS) before administration, after one week, and while on a stable dose. Result: 44 patients were enrolled during this period and 19 patients completed the study. The medication and the survival period on average were 52.0 and 67.2 days, respectively. The average gabapentin daily dose after one week was 358 mg. The average period needed to reach a stable dose was 11.6 days and the average stable daily dose was 463 mg (male 620 mg, female 289 mg). The mean NRS decreased from 5.7 (before) to 2.1 (after one week, p<0.001) and 1.9 (stable dose, p<0.001), respectively. 57.9% of patients showed side effects, somnolence in 52.6%, delirium in 5.3%, tremor in 5.3%. Conclusion: Gabapentin can be expected to be effective and safe for managing cancer-related neuropathic pain for a long period even when in critical condition through careful titration. Palliat Care Res 2011; 6(1): 101-108

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Purpose: We conducted a group seminar for lung cancer patients. The purpose of the group seminar was to eliminate the negative notions about opioids and to impart the right knowledge about these drugs. Further, we investigated the notions about opioids and the effectiveness of the group seminar. Methods: A pharmacist conducted a group seminar on opioids for lung cancer inpatients who agreed to participate in the group seminar. Moreover, we performed a questionnaire survey before and after the delivery of the group seminar. Results: Sixty patients answered the questionnaire. After completion of the group seminar, the understanding and knowledge about opioids increased, as indicated by the responses of the patients to all of the questions. Conclusion: Complete elimination of the negative notion about opioids could not be achieved through the group seminar. However, the group seminar was thought to be one of the useful methods of educating patients. If a patient resists treatment with opioids, control of pain may be delayed. This in turn would hamper improvement of the quality of life. Therefore, we consider that it is necessary that a patient has the right knowledge about opioids beforehand. Palliat Care Res 2011; 6(1):109-118

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Purpose: We evaluated the efficacy of continuous administration of epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) in patients with end-stage non-small cell lung cancer. Method: Our study included 33 patients most recently treated with EGFR-TKI for non-small cell lung cancer that had once been responsive to EGFR-TKI but eventually showed worsening. We compared patients who discontinued EGFR-TKI within one month (n=16) after their disease progressed and those who continued the treatment (n=17). Results: The median survival time was significantly longer in patients who continued EGFR-TKI (191 days) than in those who discontinued the treatment (62 days) (p=0.0098). Adverse events experienced by patients who continued the treatment included Grade 1 eruption in six, Grade 2 eruption in one, Grade 1 diarrhea in one and Grade 1 AST/ALT elevation in four. All of these adverse events were manageable. Conclusion: In patients with non-small cell lung cancer initially responsive to EGFR-TKI but eventually showing worsening and becoming unfit for cytotoxic anticancer drugs, continuous administration of EGFR-TKI may extend their survival with acceptable toxicity. Further investigation of this strategy is warranted. Palliat Care Res 2011; 6(1): 119-125

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The purpose of this study was to investigate the relationships among the intention of palliative care nurses to leave their profession and work-life balance, organizational climate, and health status with the objective of exploring the factors that prompt nurses to leave their profession. A cross-sectional survey of 105 palliative care unit nurses working in 7 facilities in prefecture A was conducted using an anonymous, self-completed questionnaire between March and April 2010. Data on eighty-three respondents (response rate, 79.0%) were used. The results were analyzed using a multiple regression analysis with ‘intention to leave profession’ as the dependent variable. The results of the analysis revealed that the organizational climate, the evaluation scores for work and life, and the degree of fatigue were significantly related to the intention of nurses to leave their profession. These results suggest that to reduce the intentions of nurses to leave their profession, improving autonomy within organizational climates and reducing fatigue and low estimates of work-life balance are important. Palliat Care Res 2011; 6(1): 126-132

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This study examined the content validity and issues in the program management of a comprehensive support program for cancer patients. The program included a seminar for patients, a newsletter, a support cafe, support group, a yoga and stretching class, and a hand and foot care class. Program evaluation was conducted three times (before program, During program: 6 months later, After program) using an original questionnaire, MAC, and FACIT-SP. Forty subjects were included in the study. Subjects responded that they were satisfied with the knowledge and information obtained through the program, as well as the personal connections established with medical personnel. The physical intervention portion of the program was positively evaluated, and the emotional and spiritual QOL of patients improved significantly after the program. These results suggest that the program effectively supports the active lives of cancer patients. Palliat Care Res 2011; 6(1): 201-208

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Purpose: We developed a database that can be shared by the members of our palliative care team (PCT) before the conference and ward round (CR) to make these activities more efficient. Methods: The database was developed using Microsoft Access®. The condition of patients was evaluated using a Japanese version of the Support Team Assessment Schedule (STAS-J). The database allows any member of the team to input patient information. We also developed a form that allows us not only to share the information but to continuously observe the progress of the patients. To evaluate the advantages of the database on CR, we compared the number of patients observed in one CR and the number of CR's per patient before and after the introduction of the database. Results: The number of patients observed in one CR and the number of CR's per patient were significantly increased after the introduction of the database. Conclusion: The database had positive effects on CR by making the patient information available in advance and by allowing continuous evaluation of patients. Palliat Care Res 2011; 6(1): 209-215

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Purpose: The purpose of this research is to examine nursing practices in which nurses experienced a realization of spirituality and their thoughts at that time. Methods: A questionnaire was administered to nurses in four hospitals and one palliative care unit. Results: A total of 835 participants completed the questionnaire. Nearly 20% of nurses reported having spiritual experiences associated with their work, including realizations of the value of human life and patients' strength in facing death or living with illness. In addition, nurses achieved a sense of spirituality through transcendent occurrences related to life and death, such as premonitions. Nurses pondered providing care that transcends both mind and body after encountering difficulty in providing nursing care. Conclusion: Nurses' sensitivity to human life and death and transcendent occurrences may be a reflection of the unique features of Japanese spirituality. In order to enhance Japanese nurses' perceptions of spirituality, it is necessary to offer nursing education in spirituality related to each nurse's own experiences. Palliat Care Res 2011; 6(1): 216-221

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We experienced a case that right massive pleural effusion was successfully controlled with Denver shunt from the right chest cavity to right femoral vein. A 80-years-old woman had received hemodialysis due to chronic renal failure twice in a week. She was diagnosed as right breast cancer and underwent right breast conserving surgery at December, 2008. In postoperative follow-up duration, she had difficulty in breathing and visited to the emergency room in our hospital. She was diagnosed as respiratory failure due to right massive pleural effusion from the X-ray result and the blood gas analysis. There was no pleural effusion within the left chest space. No malignant cell was detected in the effusion. We thought that diuretics and shunt tube from the right chest cavity to the abdominal cavity would be ineffective because of her chronic renal failure, and for that reason, we placed the shunt tuve from the chest cavity to the right femoral vein. Respiratory failure and the quality of life were successfully improved for about 7 months by using it. Palliat Care Res 2011; 6(1): 301-307

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Purpose: Acute hemorrhagic rectal ulcer (AHRU) commonly occurs in elderly who are bedridden for long time due to severe underlying diseases such as cerebral and myocardial infarction and their complications. However, it is uncommon in end-stage cancer patients receiving palliative care. We report a rare AHRU case in his forties who had lung cancer with paraplegia due to tumor invasion. Case: A male lung cancer patient was admitted to our hospital for new-onset paraplegia caused by spinal cord invasion. On 25th day after admission, he suffered from a little rectal bleeding. From that day, a painless rectal bleeding becomes gradually increased. On 37th day, a massive bleeding was occurred. Endoscopy showed that there was no active bleeding but an exposed vessel and partial circumferential ulcer in the lower part of rectum, which was compatible with the finding of AHRU. The lesion was successfully treated by clipping and no re-bleeding was observed after clipping. He was discharge on 103rd day. Conclusion: AHRU should be considered in the differential diagnosis of a massive melena in end-stage cancer patients. Prompt diagnosis and therapy is important because this disease is curable even in the terminal stage to improve their quality of life. Palliat Care Res 2011; 6(1): 308-312

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We report a case whose left lower limb neuropathic pain accompanied by pelvic tumor invasion was remarkably eliminated by ultrasound-guided sciatic nerve block. Case report: The subject was a sixty year old male. Pharmacological therapy was given according to the WHO analgesic ladder, but his left lower limb pain failed to respond to drugs. His intractable lower limb neuropathic pain was alleviated by ultrasound-guided sciatic nerve block. Drug delivery can be achieved with a percutaneous catheter and a disposable infusion pump. Infusions were run at 5mlh^-1 with 0.1% ropivacaine. Conclusion: Neuropahic pain is sometimes hard to be controlled only by opioids or adjuvant analgesics, but there is a possibility of providing pain relief by combination use with nerve blocks. Interventional techniques can be highly effective but also have the potentiality to produce significant adverse effects. Many patients have factors which would be considered a near absolute contra-indication to the use of nerve blocks such as immuno-compromise or impairment of coagulation. Skillful application of peripheral neural blockade with ultrasound imaging broadens the options for providing optimal pain management. Palliat Care Res 2011; 6(1): 313-315

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It is not uncommon for edema in the end stage of advanced cancer to be caused by nephrotic syndrome (NS) as well as by cachexia, hypo-proteinemia due to malnutrition, or lymphedema. Such edema not only causes patients' quality of life (QOL) to be deteriorate, but may also result in earlier death in the absence of accurate diagnosis and treatment. We report a case of nephrotic syndrome with advanced uterine cancer, in which the patient's QOL was greatly improved by the accurate and timely diagnosis and treatment of NS. A 65-year old woman suffering from recurrent uterine cancer (lung and brain metastases) was admitted as an emergency due to deterioration of her general condition. Edema of both legs was severe, and laboratory findings (TP 5.0 g/dl, ALB 1.3 g/dl, T-Chol 369 mg/dl, proteinuria 3+) at the time of admission met the diagnosis criteria for NS rather than cachexia. We first administered albumin to stabilize circulation, and started treatment with prednisolone and cyclosporine, which greatly improved her general condition and edema of her legs. Subsequently, NS repeatedly improved and worsened and the tumors gradually progressed. The patient died of multiple organ failure induced by disseminated intravascular coagulation (DIC) at 81 days after admission. NS caused by malignancy is not uncommon. In general, however, such cases of NS are associated with solid tumors, such as gastrointestinal and lung cancer. NS caused by uterine cancer is very rare. We suggest that NS should be borne in mind in addition to cachexia, hypo-proteinemia or lymphedema as a possible cause of edema in the end stage of advanced cancer. Palliat Care Res 2011; 6(1): 316-323

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Mohs' paste is a histopathological fixative with zinc chloride as the main ingredient. It has been applied to perform chemosurgery of skin tumors. In recent years, this paste has been reportedly very effective for control of various symptoms of skin metastasis in inoperable advanced cancer, such as pungent odor and hemorrhage in the field of palliative care. Shigeyama et al. modified the composition of the original Mohs' paste in order to regulate its viscosity; they added glycerin to a mixture of zinc chloride and zinc oxide. However, there may be difficulty in pasting this agent to a target region, because of its very high viscosity. Therefore, we devised two methods to overcome this difficulty; one was to paint the surface of a small piece of gauze with Mohs' paste, and the other was to apply the paste directly on the gauze and apply it to a lesion. We called the above two modifications, "Mohs' gauze method A and B." Mohs' gauze was used for the treatment of hemorrhage, pungent odor and huge exudate from a metastatic skin tumor of gastric cancer. These conditions disappeared without any side effects. We did not recognize the difference in fixation effect of the lesion between the conventional Mohs' paste method and our Mohs' gauze methods. Our method should make the Mohs' paste easier to apply, and might extend its indication. Palliat Care Res 2011; 6(1): 324-329

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Purpose: Traditionally, opioids have been the cornerstone of therapy for patients suffering from cancer pain, regardless of the potential to develop opioid tolerance. In chronic pain patients who experience improving pain by opioid rotation, the clinical role of opioid tolerance is gaining more recognition. Case Report: Presented here is the case of a 60-year-old man with recurrent rectal carcinoma with huge pelvic mass and iliac and neck of femur bone metastases, suffering with intractable 9/10 pain on the numerical rating scale in his right hip and leg. In spite of escalating doses of fentanyl to 50.4 μg/72 hours and started gabapentin for adjunctive pain treatments, the patient continued to experience severe pain. The clinical picture suggested the possibility of opioid torelance. We decreased the fentanyl dose and started oxycodone. Opioid rotation to 30 mg/day sustained release oxycodone and withdrawed fentanyl provided effective pain control. The patient's pain level dropped to a more acceptable 2/10. He was more alert, and his pain was tolerable until his death. Conclusion: Opioid tolerance might be considered in a patient who has no evidence of disease progression, who is on clinically reasonable doses of opioids. Opioid rotation may provide a favorable clinical outcome in those patients who have failed to benefit from adjunctive pain treatments. Palliat Care Res 2011; 6(1): 330-335

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Purpose: We report successful treatment of a patient with delusions and hallucinations by using electroconvulsive therapy (ECT) at a palliative care unit (PCU). Case Report: A female patient in her thirties was diagnosed with recurrent ascending colon cancer and metastatic lung cancer. On the 18th day after admission to our PCU, she developed severe delusions and hallucinations with catatonia. She was unable to take medicines orally because of obstruction of the digestive tract. Further, standard treatment using intravenous haloperidol was ineffective. We repeatedly evaluated her psychiatric and somatic status and administered ECT under general anesthesia (midazolam, propofol, and suxamethonium chloride). The decision to administer ECT was made by the members of a multidisciplinary team. On the 1st day of ECT, delusions and hallucinations were markedly reduced. These symptoms disappeared after 4 courses of ECT for 3 days, and she returned to normal clinical status without demonstrable side effects. The levels of serum creatine phosphokinase and electrolytes were in normal range. Conclusion: ECT is a highly effective treatment for psychiatric disorders and can be administered to a special population of patients (for example, pregnant women, elderly patients, patients resistant to treatment, and patients in emergency). Our experience indicates that ECT is an effective and relatively safe procedure of choice for terminally ill cancer patients. Palliat Care Res 2011;6 (1): 336-339

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