Exacerbation of Emesis and Dysphagia with Oxycodone Dose Escalation in a Patient with Lung Cancer, Possibly Associated with Complicated Esophageal Achalasia

<p>Objective: We describe a case of lung cancer complicated with esophageal achalasia (EA), which was successfully treated with endoscopic pneumatic dilation (EPD). Case: A 66-year-old woman was admitted to our hospital because of frequent episodes of emesis and dysphagia after receiving an escalating dose of sustained release oxycodone (SRO) for cancer-related multifactorial back pain. She had been diagnosed with EA and treated with EPD at the age of 50. Her symptoms were refractory to the conventional anti-emetic agents such as prochlorperazine and metoclopramide. Computed tomography imaging showed marked dilatation of the esophagus with food residue. We diagnosed EA based on the presence of rosette-like esophageal folds on endoscopy and narrowing of the esophagogastric junction on esophagography, and subsequently performed EPD, which alleviated the symptoms. Discussion: The effects of opioids on esophageal motility have not been elucidated thus far. Recent studies using high-resolution manometry reported that long-term use of opioids was associated with esophageal dysmotility similar to that observed in EA. Although we have no evidence to directly demonstrate the causal relationship between the use of SRO and anti-emetic agents and EA, we speculate that our patient’s symptoms might be associated not only with SRO-related emesis during the gradual worsening of EA, but also partly with the SRO-induced esophageal dysmotility and the constrictive effect of dopamine D₂ receptor antagonists on the lower esophageal sphincter. Care must be taken to avoid drug-induced esophageal motor dysfunction, which might lead to deteriorate EA. </p>

Appearance of Skin Moisturization in the Final Stage of life - A Prospective Observational Study with Clinical Pathway for End-of-Life Care (Liverpool Care Pathway Japanese Version) in Palliative Care Unit / 日本農村医学会雑誌

　　Objective: To elucidate the appearance of skin moisturization (cold and clammy skin) indying period and related factors. Methods: Patients were observed prospectively with skin moisturization using the clinical pathway for end-of-life care (Liverpool Care Pathway Japanese version [LCP]) by nurses in the palliative care unit. Results: Of 213 patients placed on LCP, 48 (22.5%) indicated skin moisturization, which was observed mostly in summer and in the morning. It appeared 45.8 hours before death on the average. By multivariate analysis, the administration of non-steroidal anti-inflammatory drugs (NSAIDs) was an independent related factor. Conclusions: Compared to our previous retrospective study, the appearance of skin moisturization was higher in frequency and earlier in the dying period, and the administration of NSAIDs was an independent related factor.

The Relation between Self-Contribution Degree of Members of Palliative Care Team and Improvement in the Symptom Items Listed in STAS-J / 日本農村医学会雑誌

　　Purpose: To elucidate the degree of self-conctribution of each member of a palliative care team and the palliative effect patients. Patients and Methods:The degree of self-contribution to intervened patients and the degree of improvements in the symptoms items listed in a Japanese version of the Support Team Assessment Schedule (STAS-J) were examined prospectively. Results: The degree of self-contribution was often higher in doctors, nurses, clinical psychotherapists and pharmacists, and lower in nutritionists. It was related to age, gender, site of primary disease and the duration of intervention. The symptom items which showed improvement were such items as pain, nausea, vomiting, appetite loss and insomnia, but delirium and depression worsened. The degree of self-contribution and the degree of improvement in symptom were correlated in seven items in the case of pharmacists but only in one in the case of other professionals. Discussion: The degree of self-conribution varied and was not always high even after the intervention of the care team. It was considered that the fact that the number of related items was larger in pharmacists than in any other professionals was probably because the pharmacists could assess the symptoms and propose drugs from an objective point of view, although character might be mostly involved. Conslusion: It is to be hoped that every one engaged in palliative care will do what is one’s forte and apply each one’s individuality properly in the future.

Pigmentation by transdermal fentanyl patch

<b>Introduction</b>: There has been no case report in which hyperpigmentation developed on the skin area where a transdermal fentanyl patch was applied in a patient. <b>Case report</b>: 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. <b>Discussion</b>: 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. <b>Conclusion</b>: We should pay a careful attention to hyperpigmentation of the skin where a transdermal fentanyl patch is applied.

Pregabalin provides remarkable relief of refractory pruritus: a case report

<b>Introduction</b>: It is difficult in the treatment for the patients with refractory pruritus by conventional oral or external medication. <b>Case report</b>: 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. <b>Discussion</b>: A few previous research of effectiveness on pregabalin for pruritus have been reported from abroad. The improvement for refractory pruritus was provided by pregabalin. <b>Conclusion</b>: We conclude that pregabalin is a one of the options for effective treatment for refractory pruritus.

A Case of Breast Carcinoma with Multiple Bone Metastases Intervened by Palliative Care Preceding Chemotherapy / 日本農村医学会雑誌

　　This case is a 56-year-old woman. With multiple bone metastases, she was referred to the Department of Palliative Care on the same day as core needle biopsy had just been performed in the Department of Surgery. Aggressively increased oxycodone was administered to relieve her significantly severe pains by bone metastases. After relief of the pains, cancer chemotherapy of EC and weekly PTX regimens were performed parallel to palliative care. In this case, chemotherapy could be performed after the pains had been sufficiently relieved with closer cooperation between the palliative care doctor and the attending surgeon. It is important for patient-focused medical care to be delivered by both the attending doctor administering cancer treatment and the palliative care doctor working for relief of the symptoms, while they are striving to foster their tie-up.

An Experience in Administration of EPA-Enriched Nutritional Supplementation (ProSurer^®) for Lung Cancer Patients with Chemotherapy / 日本農村医学会雑誌

The initial case was a man in his 50s. He received 2 cans a day of ProSure^®, while undergoing radiation and chemotherapy with carboplatin and docetaxel for adenocarcinoma in the lung. His body weight rose from 62.4 kg on admission to 63.7 kg before discharge, CRP decreased from 3.08 mg/dl to 0.48 mg/dl, and albumin fell from 3.6 g/dl to 3.5 g/dl. The second case was a man in his 60s. He was diagnosed as having squamous cell carcinoma in the lung and administered with 2 cans a day of ProSure^® and antibiotics. One-and-a-half months later, he underwent chemotherapy with carboplatin and S-1 and radiation. His body weight stood at 47.0 kg on admission and 47.2 kg before discharge, CRP dropped from 15.45 mg/dl to 3.26 mg/dl, and albumin was retained at 2.6 g/dl to 2.7g/dl. The administration of ProSure^® brought about improvements in the nutritional status and anti-inflammatory effects in the patients with chemotherapy.

Malignant Fibrous Histiocytoma Patient Who Survived for Over Five Months in Only Palliative Care Despite Marked Thrombocytopenia and Jaundice After Transferal to Our Hospital / 日本農村医学会雑誌

  The patient was a woman in her 70s, who had been diagnosed as having a malignant fibrous histiocytoma in the right axilla with invasion to the intrathoracic space at a local hospital. The growth of cytokine-producing tumor was suspected, and thrombocytopenia caused by bleeding and jaundice by blood transfusion were disclosed. When she was admitted to our palliative care unit, the platelet count was 19,000/μl and total bilirubin was 6.4mg/dl. Furthermore, several predictive fools showed the prognosis for survival was poor. After transferal to our hospital, the patient was treated mainly with medication. No blood transfusion was given. In the clinical course, the platelet count and total bilirubin level were restored to normalcy. The patient lived on for another five months or over. The contributing factors, in prolonging her life longer than predicted were probably as follows; (1) spontaneous recovery of thrombocytopenia without bleeding, (2) improvement of jaundice caused by the blood transfusion, and (3) foods taken orally even in small amounts. There are patients whose prognosis varies substantially in the fields of the palliative care. It is important to work out proper medical treatment and care plans according to symptoms and the status of patients.

Implementation of Liverpool Care Pathway Japanese version to electronic medical chart (FUJITSU HOPE/EGMAIN-FX®)

Liverpool Care Pathway (LCP) Japanese version was implemented to electronic medical chart (FUJITSU HOPE/EGMAIN-FX®). The processes were needed as follows; preparation of each templates (criteria for use of the LCP/initial assessment, ongoing assessment, and care after death), preparation of pathway/regimen, incorporation of the templates to the pathway and approval in our hospital clinical pathway committee. One problem we encountered was whether to choose an Excel or a template format for each assessment sheet, and the template format was selected as it presented us with a higher degree of convenience, since each field can be expanded into a table on the screen without scrolling and there is little limitation in the letters of the valiance records that can be used in the template format. The complexity of the three records, “the pathway”, “SOAP & focus” for recording opioid use, and “the progress sheet” for recording vital signs, in addition to the inability to expand enough to capture the same field and show changes in the daily pathway over time through night and day work shifts remain a challenge and need to be improved in the future.

Mirtazapine provided remarkable relief for refractory nausea and vomiting by sunitinib and oxycodone in a patient with renal cancer

<b>Introduction</b>: Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) and the previous reports show that may reduce nausea by inhibition of the serotonin 5-HT3receptor. <b>Case report</b>: A 38-year-old woman with advanced renal cancer with distant metastases was administered by sunitinib and oxycodone. Refractory nausea and vomiting developed during the course and mirtazapine at a daily dose of 1.875 mg was begun. The patient's nausea improved during the next day, and furthermore, by increasing the daily dose to 3.75 mg, vomiting was also improved on the third day. The therapy could be continued without withdrawal of sunitinib and oxycodone due to digestive symptoms. Although somnolence might be induced at a daily dose of 15 mg, the present low-dose mirtazapine could improve digestive symptoms without somnolence. <b>Conclusion</b>: We conclude that low-dose mirtazapine is one effective option for refractory nausea and vomiting during administration of sunitinib and oxycodone.

Significance of Mini-Lecture in ‘Cancer Salon-Kirameki’ / 日本農村医学会雑誌

Background: In our hospital, a mini-lecture is given before a social gathering during “Cancer Salon-”<br>Purpose: To examine Significance of the mini-lecture.<br>Method: The results of a questionnaire survey of the participants were summarized.<br>Results: The mini-lectures were performed by multidisciplinary persons. The survey found that a significantly large number of the participants felt the mini-lectures by persons other than medical doctors were helpful (p=0.021).<br>Discussion: Mini-lectures are valuable in that they provide not only information but also “create an atmosphere” of the following meeting. In addition, to receive a favorable assessment from the audience, it is important for the speakers, even the doctors, to understand the feelings of the participants, and take part in the subsequent get-together without formality.<br>Conclusion: The mini-lecture creates an atmosphere toward the social gatherings, and leads the speakers to adapt to the occasion with the participants.

Successful Pain Control in Cancer Patient on Palliative Therapy by Partial Opioid Rotation / 日本農村医学会雑誌

  Our palliative care team intervened in a patient with sciatica resulting from metastasis to sacral bone after surgery for rectal cancer. Rapid pain control and a change in the route of rescue drug administration from the stoma were needed. Partial opioid rotation was performed. The dose of 25.2 mg in 72 hours in a transdermal fentanyl patch decreased to 16.8 mg in 72 hours, and the dose of 3.6mg in an hour by continuous intravenous injection of morphine was added. The change in the rescue root to intravenous administration by a patient-controlled analgesia pump gave the patient relief from his pain. He was able to attend his daughter's wedding. His family were all pleased with the relief provided. The advantages of this partial opioid rotation are summed up in the following three points: (1) The required time is relatively short; (2) It can be expedient for analgesia due to the addition of different opioids; and (3) The partial opioid rotation produces fewer adverse effects than a full opioid rotation. Adjustment of the amount of drugs for pain relief in cancer patients is important with the situations of the patient and the family taken into consideration fully.

Local drainage for Fournier's gangrene developed in palliative care unit provided pain relief in a terminally ill patient with bladder cancer

This paper presents the case of a man in his 70's with local advanced bladder cancer with hospital-developed Fournier's gangrene. The patient was hospitalized at the palliative care unit, and drainage with incision of the scrotum for symptom relief was performed to relieve severe pain. The patient experienced pain only during changing of the wound's dressing and no pain at rest after the operation. Furthermore, he reached his birthday and spent time in peace with his family. Fournier's gangrene is the necrotizing fasciitis of perineal and anal lesions, in which inflammation progresses rapidly in wide lesions, and it is associated with a high mortality rate. For Fournier's gangrene in a terminally ill patient, current agreement might depend on the patient's goal of treatment. The drainage provided for spiritual care of the patient and his family as well as pain relief. In conclusion, local drainage for Fournier's gangrene can be feasible as a choice of palliative treatment. Palliat Care Res 2011; 6(2): 340-343

Low-Dose Mirtazapine Effecting the Remarkable Improvement of Nausea in a Patient with Primary Hepatocellular Carcinoma: A Case Report / 日本農村医学会雑誌

  The case was a man in his 80s, who had been in home care with primary hepatocellular carcinoma before hospitalization. He suffered nausea and appetite loss. However, hypercalcemia in laboratory data, brain metastasis on head CT and MRI, and intestinal obstruction or dilatation on abdominal CT, were not revealed. Upper gastrointestinal endoscopy detected no mechanical abnormality after admission to hospital and medical treatment with 3.75mg/day of mirtazapine was started. The dietary intake increased on the following day of the administration and nausea and appetite loss were improved, so the patient was discharged. In conclusion, low-dose mirtazapine was considered to be one of the effective therapeutic agents for nausea from unknown causes in cancer patients.

Success in Pain Management by Switch from Gabapentin to Pregabalin: A Case of Lung Cancer / 日本農村医学会雑誌

  The patient was a woman in her 80s, who was referred to the palliative care team in our hospital for pain due to bone metastases from lung cancer. Although gabapentin and ifenprodil tartrate were administrated in addition to opioids and loxoprofen sodium, and the dose of opioids was increased, pain was not relieved remarkably. A switch from gabapentin to pregabalin brought remarkable pain relief. Before the internal use of pregabalin, the patient was often seen lyiing in bed because of pain. However, by pregabalin, she began to walk, pushing her wheelchair and smile often. Her ability to perform the basic activities of daily living was improved. The switch from gabapentin to pregabalin was one effective option when an analgesic adjuvant for cancer pain was chosen.

Alleviation of Symptoms by Palliative Care Team in Two Cancer Patients Receiving Chemotherapy / 日本農村医学会雑誌

  One patient was intervened by our palliative care team (PCT) to relieve neuropathic pain due to postoperative recurrence of rectal cancer. The dosage controlled-release oxycodone was increased, analgesic adjuvant drugs were changed and the administration of betamethasone were started. Furthermore, the number of times the patient took controlled-release oxycodone increased two to three times a day. These changes in medication resulted in relief of symptoms. Cetuximab therapy was given twice during the course. The other patient was intervened by the PCT for right upper limb pain and dyspnea due to postoperative recurrence of breast cancer. Morphine sulfate hydrate and analgesic adjuvant were additionally given. As pain increased three days after the administeration of transdermal fentanyl patches, the patches were changed every other day, instead of every three days. FEC100 therapy was given twice during the course. In the present two cases, the PCT was intervened with great zeal and rapid relief of symptoms resulted. In the meantime chemotherapy proceeded uneventfully. We thought that trust of the chief doctor in the PCT was most important for effective intervention.