Background: In terminally ill patients with cancer, sleep disturbance makes worse their quality of life. Midazolam has not ever been used for the treatment of sleep disturbance in general wards of our hospital, used in palliative care unit of other hospital, however. Method: This is a retrospective study based on chart review. Twenty-eight patients who were treated with midazolam for sleep disturbance included in this study. We designed evaluation methods to strictly follow the actual chart descriptions. Efficacy was rated as good, fair, or poor. Safety was defined by the presence or absence of respiratory depression and hypotension. Results: The median administration periods and initial doses were 6 days (range, 1-151) and 5.0 mg/night (1.8-20.0), respectively. Fourteen patients showed good sleep a night after midazolam infusion, four and nine patients showed fair and poor sleep, respectively. No patient demonstrated a respiratory rate of less than 8/min and systolic blood pressure of <60 mmHg at any point during and after midazolam infusion. Conclusion: Intravenous midazolam appeared to be safe for sleep disturbance of terminally ill patients with cancer in general wards. A future improvement administration methods are necessary to treat for sleep disturbance more effectively as well as PCU.

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Background: The palliative care unit (PCU) at the National Cancer Center Hospital East changed the administrative policy to strengthen the transition to palliative home care. This study aimed to identify the factors tended to transfer to palliative home care in Japan. Methods: We reviewed the medical records of consecutive cancer patients admitted to our PCU during period from October 2010 until September 2011. Patients with performance status 4 and duplication were excluded in this study. We identified variables associated with the discharged group and the others group, using the univariate and multivariate analyses. Results: There were 223 patients (Pts) during periods, 63 Pts (28.3%) discharged to palliative home care and 160 Pts (71.7%) deceased in our PCU. Univariate and multivariate analysis identified: admission from their own home, a good PS of ≤ 2, good oxygen saturation, a good amount of oral intake, maintain of PS at day 15, no dyspnea and no abdominal distention as predictions of a transition to home from our PCU. Conclusion: Our study indicated the factors tended to transfer to palliative home care from PCU in Japan, however this study had some limitations. A prospective study is required to validate these factors.

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The primary aim of this study was to investigate the reliability and validity of a measurement tool to quantify the quality of communication and cooperation among health care providers in a region. A total of 476 health care professionals were enrolled. For the 25-item scale, the internal consistency was excellent. Factor analyses identified 7 underlying factors, such as easy communication with health care providers in other institutions, understanding the role of other disciplines in the region, and knowing the face, name, and the way of thinking. The total score had weak negative but significant correlations with the cooperation subscale of the Palliative care Difficulties Scale. The total score was also significantly associated with the general evaluation of communication and cooperation in the region, the number of participations in whole-region multidisciplinary conferences, the number of persons to whom the respondent could ask about palliative care in the region, and clinical experience in the region. In conclusion, this scale can measure the quality of communication and cooperation among health care providers in a region with acceptable reliability and validity.

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Purpose: Olanzapine has antiemetic activity for chemotherapy-induced nausea and vomiting (CINV). The purpose of this retrospective study is to evaluate the efficacy of olanzapine for prevention of CINV in patients with severe nausea resistant to standard antiemetic regimen for highly emetogenic chemotherapy (HEC). Methods: Olanzapine was administered in twenty gynecological cancer patients receiving HEC. They had grade 3 nausea (CTCAE ver.4.0) for the acute (24 hours postchemotherapy) and/or delayed (24-120 hours postchemotherapy) period despite the combined use of 5-HT3 receptor antagonist, NK-1 receptor antagonist, and dexamethasone. Oral olanzapine (5 mg/day) was administered on day -1 prior to chemotherapy and continued for 7 days in combination with standard antiemetic regimen. The nausea control rate (grade 0-1) with olanzapine were evaluated. Results: The nausea control rate improved from 30% to 95% for the acute period, 0% to 95% for the delayed period, and 0% to 90% for the overall period. In each period, the nausea control rate improved significantly (p≤0.001). Grade 0-1 sleepiness was observed but there were no grade 3 or 4 toxicities. Conclusion: In this study, olanzapine combined with the standard antiemetic regimen had good antiemetic activity at both acute and delayed period in most of chemotherapy-naive patients receiving HEC. The efficacy of olanzapine suggested additional improvement in the control of severe CINV resistant to standard antiemetic regimen for HEC.

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Purpose: It is critical to reduce complications associated with the central venous access port (CV-port) system for patients who were treated with chemotherapy or palliative care. Methods: From October 2006 to December 2011, 68 colon cancer patients who were treated with outpatient chemotherapy via a CV-port in the Center for Clinical Oncology, Okayama University Hospital, were analyzed retrospectively. Results: CV-port related complications occurred in 20 (29.4%) patients. No blood could be aspirated in 15 patients when treated via a CV-port. Among the patients with no blood aspiration from their CV-port, ten cases had no complications other than failure of blood aspiration, and anticancer agents have been successfully administered. However, the other five patients had their CV-port system replaced due to complications. Subclavian and left side insertions were the risk factors for catheter occlusion or inability to aspirate blood. Conclusion: Medical staffs should be aware that approximately one-third of the cases with no blood aspiration potentially have troubles with their CV-ports that need to be replaced.

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Background: Palliative care has been advocated to be administered in the early phase of cancer treatment. However, little is known concerning the recognition of palliative care in general citizens. We have conducted promotional activities for palliative care as “Nonohana Project” since 2009. The aim of the current study was to investigate the awareness of palliative care in the general public in Okayama Prefecture. Methods: We performed telephone questionnaire survey about palliative care for a total of 600 general citizens aged 20 or over in Okayama Prefecture. This survey was conducted in 2009 and 2010, and we compared those results. Results: Two hundred twenty four people (37.3%) have heard of the phrase “palliative care” in 2009 and 219 people (36.5%) in 2010. The recognition of palliative care stayed at the same level as in the previous fiscal year. In those with a history of cancer of themselves or their family, the recognition was slightly increased (41.6% in 2009 and 43.2% in 2010). There were many people who were interested in palliative care in both 2009 (87.9%) and 2010 (86.3%). Conclusion: Our study indicated that many people still had no idea of palliative care in Okayama Prefecture, despite of our promotion and effort for 1 year. However, many were interested in palliative care, suggesting a need for continuous promotion to increase the understanding of palliative care.

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Purpose: The research is aimed at the evaluation of management of pain in elderly cancer patients receiving home-based care. Methods: A questionnaire of 29 questions was developed and 323 home-care physicians were invited to answer the questionnaire with an online system from January 19 to 25 2011. According to answers from the general physicians, we compared the differences of answers about managements of cancer pain between two groups (>75 years old cancer patients with or without cognitive disorder) by Pearson's chi-square test. Results: In a the question “Are patients able to appropriately express their cancer pain?”, the ratio of physicians' answers was different;, positive answers in the patients' group with cognitive disorder was significantly lower than those without cognitive disorder (p=0.0043). In other questions “Do physicians feel difficulty of assessment of analgesic effect of opioids?” and “Do physicians feel difficulty of dose-selection and adjustment of opioids?”, positive answers in patients' group with cognitive disorder were more dominant than those without cognitive disorder (p<0.0001 each). Further, in the question “Do physicians feel cancer pain management is well-done?”, positive answers were significantly lower in patients with cognitive disorder than those without cognitive disorder (p<0.0001). Conclusion: With the analyses of the answers from the physicians, we found that physicians felt difficulty of both the assessment of pain and analgesic effect of opioids in patients with cognitive disorder. It should be required for the physicians to improve pain management, especially to the patients with cognitive disorder.

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Purpose: Blepharospasm is a condition characterized by abnormal contractions or twitching of the eyelid due to excessive contractions of the orbicular muscle. The purpose of the present study was to clarify the prevalence and severity of blepharospasm in end-term cancer patients and to clarify the correlation between agonal facies and angor animi or blepharospasm. Method: Diagnoses were made using the Wakakura method and the nictitating stress test, and the severity of the condition was evaluated on the basis of a palpebral dystonia grade classification system. In this positive observational study, all patients were hospitalized in our institution between October and December 2010. Result: Of the 51 evaluations, 19 (37.3%) were diagnosed with blepharospasm, and the severity of nine was ≥3 according to a five-point grading scale. Many cases were treated using antipsychotics or benzodiazepine, and an improvement was observed in all the seven cases that had medication adjustments. Diagnostically, there was no correlation between glabellar lines and pain. Agonal facies in end-term cancer patients included elements of blepharospasm in addition to angor animi. Conolusion: Blepharospasm frequently occurred in patients admitted in the palliative care unit, and it decreased their quality of life. It is important to evaluate this condition and to consider medication adjustments.

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Background/Purpose: The purpose of this study is to clarify the effectiveness of interventions for breast cancer patients with psychological distress by a clinical psychologist on the basis of the contents of the interventions and counseling. Methods: The participants were 20 inpatient and outpatient women aged from 33 to 73 years who had been diagnosed with breast cancer. The interventions were conducted on the basis of patients' complaints about anxiety and/or depression or by a medical doctor's request. The interventions employed unstructured, one-on-one interviews. Each interview usually lasted no more than 60 minutes. Results: The 20 cases were classified into the following categories: (1) 15 general (nonpsychiatric) cases, consisting of (1-1) 9 cases at the cancer-notification and progressive-therapeutic stages and (1-2) 6 cases at the progressive-relapse stage; and (2) 5 specific (psychiatric) cases, consisting of (2-1) 3 cases at the cancer-notification and progressive-therapeutic stages and (2-2) 2 cases at the progressive-relapsestage. As for the general cases, interventions were found to be effective in all 9 cases at the cancer-notification and progressive-therapeutic stages but in only 2 of 6 cases at the progressive-relapse stage. In specific cases, effective interventions were found at the cancer-notification, the progressive-therapeutic, and the progressive-relapsestages. Conclusion: This study suggested that interventions for breast cancer patients by a clinical psychologist are effective. The psychological interventions had two roles: to assess the patients properly and to interview the patients as purposefully as a medical team member would.

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Purpose: Death of a parent is a painful and sorrowful experience for children. The purpose of this study was to describe the nursing care provided to children who had a parent at the end of life. Methods: Data were collected through semi-structured interviews from 11 nurses working for a palliative care unit. Results: Emerging from the qualitative data analysis were five categories: gathering information about the children; laying the foundations for providing care for children; coordination for enabling children and parent to spend time together; explaining to children about the parent's situation and parent's care and participating in an interdisciplinary approach. Conclusion: Further research is needed to identify other staff roles and family needs and perspectives to provide appropriate care for children with a parent who is terminally ill.

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Purpose: As integrated medicine has been receiving more attention, therapeutic effect of plants has become more evident in recent years. However, many hospitals in Japan have not taken advantage of horticultural therapy in their palliative care unit yet. In the present study, we examined the role and the experience of horticulture as an individual therapy for patients in palliative care unit. Results and Discussion: More smiles were observed on the patients as evident from their Face scale score changes on days horticultural therapy was conducted. Coming into contact with the vital force of plants, through germination, flowering, and seed setting seemed to act as an effective care for the patients. Comparison of the nurses' daily journal and horticultural therapists' logbook showed difference in the nature of conversations recorded, indicating a specific role of horticultural therapists in palliative care. Conclusion: The study suggested a potential for individual therapy of patients with horticulture in palliative care as a part of integrated medicine that requires involvement of multiple medical disciplines.

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Introduction: It is difficult in the treatment for the patients with refractory pruritus by conventional oral or external medication. Case report: A 72-year-old woman with pancreatic metastasis of primary lung cancer, who was treated by control-release oxycodone for cancer pain and endoscopic biliary drainage for obstructive jaundice. Although external medication and oral anti-allergic agents (mirtazapine and herbal medicine) were administered for pruritus, there was no improvement. The patient was diagnosed with refractory pruritus and pregabalin was administered. After the beginning of low dose, increase of dosage provided improvement at the third day of the administration. Finally, numerical rating scale improved from 8/10 in previous treatment to 0-1/10 in following treatment, and the symptom was relieved. Discussion: A few previous research of effectiveness on pregabalin for pruritus have been reported from abroad. The improvement for refractory pruritus was provided by pregabalin. Conclusion: We conclude that pregabalin is a one of the options for effective treatment for refractory pruritus.

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Case: The patient was a man in his 40s who had undergone proctocolectomy for familial polyposis coli and extensive resection of the small intestine for removal of an intra-abdominal desmoid tumor. He presented to our hospital with abdominal pain caused by residual desmoid tumor, and diarrhea associated with the short bowel syndrome. Adequate pain control could not be achieved even with simultaneous application of 5 sheets of 100 μg/h transdermal fentanyl patches. Subsequently, the patient was treated mainly with 270 mg/day of a slow-release morphine preparation; however, the pain control remained unsatisfactory. At our hospital, the pain treatment was switched to 240 mg/day of morphine solution, which yielded prompt reduction of the pain intensity from 9/10 to 1/10 on the numerical rating scale. Discussion: Morphine is mainly absorbed from the small intestine. The initially insufficient pain control in this patient may have been attributable to the short bowel syndrome and diarrhea causing rapid excretion of the morphine before it was absorbed. Morphine solution, in contrast, starts to be absorbed approximately 10 minutes after administration, allowing adequate absorption, leading to successful pain control, even in the present patient with the short bowel syndrome.

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Objective: Spinal cord compression symptoms are complications that greatly reduce the quality of life of cancer patients. We report a retrospective study on the efficacy of and adverse reactions to high-dose dexamethasone therapy for patients with concomitant spinal cord compression symptoms. Subjects: This study included 8 patients with concomitant spinal cord compression symptoms who received high-dose dexamethasone therapy at our hospital between May 2009 and September 2011. Results: Only high-dose dexamethasone therapy was performed in 8 patients who could not undergo radiotherapy or surgery in combination. Among them, the results of manual muscle testing were improved in 4 patients (50.0%), and grades according to the modified Frankel Classification showed improvement in 5 patients (62.5%). Out of 7 non-ambulatory patients, one (14.3%) regained independent ambulation with highdose dexamethasone therapy alone and was discharged home. No serious adverse reactions were observed in any of the 8 patients. Discussion: This study suggested high-dose dexamethasone therapy to possibly be a useful option for relieving neurological symptoms in patients with spinal cord compression who cannot undergo radiotherapy or surgery in combination.

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Introduction: There has been no case report in which hyperpigmentation developed on the skin area where a transdermal fentanyl patch was applied in a patient. Case report: A 43-year-old man with recurrence of postoperative rectal cancer was treated by cetuximab plus irinotecan and panitumumab plus FOLFIRI. For cancer pain, transdermal fentanyl patch (Fentos®) was administered, and radiation from behind was performed. Hyperpigmentation then appeared on the chest and the abdominal skin sites where the patches were applied. The hyperpigmentation nearly disappeared four months after the fentanyl patch was discontinued. Discussion: The cause of the pigmentation was possibly due to post inflammatory hyperpigmentation secondary to contact dermatitis. It was desirable to conduct patch test and skin biopsy for making an accurate diagnosis. Conclusion: We should pay a careful attention to hyperpigmentation of the skin where a transdermal fentanyl patch is applied.

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Purpose: We report a case in which oral sodium valproate through a percutaneous endoscopic gastrostomy (PEG) tube for palliative decompression drainage in inoperable ileus achieved an effective drug concentration and ameliorated delirium and extrapyramidal side effects. Case Report: The patient was a male in his seventies who suffered from bladder cancer. He underwent PEG because of paralytic ileus with cancerous peritonitis. He had been receiving continuous intravenous infusion of haloperidol for the management of delirium, but needed to discontinue treatment with this agent due to tremor, an extrapyramidal side effect of haloperidol. Oral sodium valproate was therefore administered through the PEG tube for palliative decompression drainage. Plasma valproate concentrations showed effective levels, and his irritability was relieved. A good combination of sodium valproate and quetiapine fumarate allowed successful reduction of and eventual withdrawal from haloperidol, and tremor then improved. Conclusion: We often encounter difficulty with symptom control for patients who cannot use oral medications. When medication by other routes is difficult, this case suggests that sodium valproate through a PEG tube for palliative decompression drainage may be useful as a last resort for improving delirium.

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Since bibliographic items had an error, it corrects as follows.

p.158, upper right of a page
(Error) Palliative Care Research 2012; 8(1): 158-67
(Correct) Palliative Care Research 2013; 8(1): 158-67

p.158, center of a page
(Error) Palliat Care Res 2012; 8(1): 158-67
(Correct) Palliat Care Res 2013; 8(1): 158-67

p.164, center of a page
(Error) Palliat Care Res 2012; 8(1): 158-67
(Correct) Palliat Care Res 2013; 8(1): 158-67

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