Characteristics Associated with Survival in Patients Receiving Continuous Deep Sedation in a Hospice Care Unit / 한국호스피스완화의료학회지

Continuous deep sedation (CDS) is an extreme form of palliative sedation to relieve refractory symptoms at the end of life. In this study, we shared our experiences with CDS and examined the clinical characteristics associated with survival in patients with terminal cancer who received CDS. We conducted a chart audit of 106 consecutive patients with terminal cancer who received CDS at a single hospice care unit between January 2014 and December 2016. Survival was defined as the first day of admission to the date of death. The associations between clinical characteristics and survival were presented as hazard ratios and 95% confidence intervals using a Cox proportional hazard model. The mean age of participants was 65.2 years, and 33.0% (n=35) were women. Diazepam was the most commonly administered drug, and haloperidol or lorazepam were also used if needed. One sedative was enough for a majority of the patients. Stepwise multivariate analysis identified poor functioning, a high Palliative Prognostic Index score, hyperbilirubinemia, high serum ferritin levels, and a low number of sedatives as independent poor prognostic factors. Our experiences and findings are expected to be helpful for shared decision-making and further research on palliative sedation.

The Effects of Aroma Foot Baths on Stress and Sleep in Terminal Cancer Patients / 한국호스피스완화의료학회지

Purpose@#This study aimed to investigate the effects of aroma foot baths on stress and sleep in terminally ill cancer patients. @*Methods@#We performed a non-randomized interventioncontrol study with 30 terminal cancer patients who were admitted to a palliative care unit.Participants responded to questionnaires on stress and sleep before and after a 5-day interval. The intervention group received a daily aroma foot bath for 5 days. We performed multivariate regression analysis to examine the changes in outcomes on stress and sleep for the intervention group compared to the control group. @*Results@#The differences in baseline characteristics between groups, excluding subjective economic status and general weakness, did not show statistical significance. In contrast to the control group, the intervention group showed a statistically significant change in physical stress and psychological stress levels, but significant changes were not observed in quality of sleep. Compared to the control group, the intervention group showed a significant reduction in physical stress (P=0.068) and psychological stress (P=0.021). @*Conclusion@#Aroma foot baths are effective for reducing stress in patients hospitalized with terminal cancer.

The Effects of Aroma Foot Baths on Stress and Sleep in Terminal Cancer Patients / 한국호스피스완화의료학회지

Purpose@#This study aimed to investigate the effects of aroma foot baths on stress and sleep in terminally ill cancer patients. @*Methods@#We performed a non-randomized interventioncontrol study with 30 terminal cancer patients who were admitted to a palliative care unit.Participants responded to questionnaires on stress and sleep before and after a 5-day interval. The intervention group received a daily aroma foot bath for 5 days. We performed multivariate regression analysis to examine the changes in outcomes on stress and sleep for the intervention group compared to the control group. @*Results@#The differences in baseline characteristics between groups, excluding subjective economic status and general weakness, did not show statistical significance. In contrast to the control group, the intervention group showed a statistically significant change in physical stress and psychological stress levels, but significant changes were not observed in quality of sleep. Compared to the control group, the intervention group showed a significant reduction in physical stress (P=0.068) and psychological stress (P=0.021). @*Conclusion@#Aroma foot baths are effective for reducing stress in patients hospitalized with terminal cancer.

Overweight and Obesity are Risk Factors for Coronavirus Disease 2019: A Propensity Score-Matched Case-Control Study

Although obesity is a risk factor for infection, whether it has the same effect on coronavirus disease 2019 (COVID-19) need confirming. We conducted a retrospective propensity score matched case-control study to examine the association between obesity and COVID-19. This study included data from the Nationwide COVID-19 Registry and the Biennial Health Checkup database, until May 30, 2020. We identified 2,231 patients with confirmed COVID-19 and 10-fold-matched negative test controls. Overweight (body mass index [BMI] 23 to 24.9 kg/m2; adjusted odds ratio [aOR], 1.16; 95% confidence interval [CI], 1.1.03 to 1.30) and class 1 obesity (BMI 25 to 29.9 kg/m2; aOR, 1.27; 95% CI, 1.14 to 1.42) had significantly increased COVID-19 risk, while classes 2 and 3 obesity (BMI ≥30 kg/m2) showed similar but non-significant trend. Females and those <50 years had more robust association pattern. Overweight and obesity are possible risk factors of COVID-19.

Association between D-Dimer Levels and the Prognosis of Terminal Cancer Patients in the Last Hours of Life / 한국호스피스완화의료학회지

Purpose@#D-dimer levels are known to be associated with poor outcomes in patients with various cancers, but their significance at the end of life remains unclear. This study investigated D-dimer levels as a prognostic indicator for terminal cancer patients in the last hours of life. @*Methods@#The retrospective study was conducted at a palliative care unit of a tertiary cancer center, using a database to analyze the records of patients treated from January 1, 2010 to December 31, 2018. In total, 67 terminal cancer patients with available data on Ddimer levels were included. Patients’ demographic data, clinical information, and laboratory values, including D-dimer levels, were collected. Survival was analyzed using the Kaplan– Meier method and the log-rank test. A Cox proportional-hazards model was used to identify prognostic factors of poor survival. @*Results@#The most common site of cancer was the lung (32.8%) and the median survival time was 5 days. Most laboratory results, particularly D-dimer levels, deviated from the normal range. Patients with high D-dimer levels had a significantly shorter survival time than those with low D-dimer levels (4 days vs. 7 days; P=0.012). In the Cox regression analysis, only a high D-dimer level was identified as a predictor of a poor prognosis (hazard ratio, 1.83; 95% confidence interval, 1.09~3.07). @*Conclusion@#Our results suggest that at the very end of life, D-dimer levels may serve as a prognostic factor for survival in cancer patients.

Higher Prevalence of Hypertension among Individuals with Restless Legs Syndrome: A Meta-Analysis

OBJECTIVE: This study investigated the proposed association between restless legs syndrome (RLS) and the prevalence of hypertension. METHODS: A meta-analysis was conducted based on searches of the PUBMED, EMBASE, Cochrane Library, and Korean electronic databases. Cohort and cross-sectional studies reporting the incidence of hypertension in individuals with RLS were included. Dichotomous data were pooled to obtain an odds ratio (OR) and 95% confidence interval (CI) for the prevalence of hypertension in individuals with RLS. The main outcome measure of the study was prevalence of hypertension in patients with RLS compared with a control group. RESULTS: One cohort study and eight cross-sectional studies were included in the meta-analysis. Individuals with RLS had an increased prevalence of hypertension (all studies: OR=1.13, 95% CI=1.04–1.23; cross-sectional studies: OR=1.12, 95% CI=1.01–1.24). However, in subgroup analyses controlling for cardiovascular risk factors, such as diabetes mellitus and dyslipidemia, the differences in the prevalence of hypertension between RLS and control patients were no longer significant. CONCLUSION: Patients with RLS may have a higher prevalence of hypertension, according to a pooled analysis, but the results remain to be confirmed in well-designed prospective studies.

Consensus guidelines for the definition of the end stage of disease and last days of life and criteria for medical judgment

In Korea, the Hospice, Palliative Care, and Life-sustaining Treatment Decision-making Act was enacted in February 2016 in order to ensure that the patient's self-determination in end-of-life care processes is respected. To enhance physicians' understanding of this act and to provide proper criteria for medical judgment in variety of clinical settings, consensus guidelines were published in November 2016. In this article, the characteristics of these guidelines and related issues regarding the definitions of ‘the end stage of disease’ and ‘last days of life’ and the criteria for medical judgment are presented and summarized. According to the guidelines, the term ‘end stage of disease’ refers to a state in which there is no possibility of a fundamental recovery and the symptoms are expected to worsen within months. The terms ‘the last days of life’ and ‘the final days of life’ refer to a state in which, despite treatment, the patient's condition is worsening and death is impending, with no possibility of recovery. The attending physician and another relevant specialist should both judge a patient's medical condition as either ‘end stage of disease’ for hospice/palliative care or ‘the last days of life’ for dying patient care according to the law. Caregivers should provide appropriate medical information to eligible patients for palliative or ‘end stage of disease’ care through advance care planning. Therefore, it is critically necessary that caregivers understand the legitimate process of hospice/palliative and dying patient care based on the patient's wishes and best interests. Physicians should apply these consensus guidelines to eligible patients considering their clinical course and the patients' wishes.

Consensus guidelines for the definition of the end stage of disease and last days of life and criteria for medical judgment

In Korea, the Hospice, Palliative Care, and Life-sustaining Treatment Decision-making Act was enacted in February 2016 in order to ensure that the patient's self-determination in end-of-life care processes is respected. To enhance physicians' understanding of this act and to provide proper criteria for medical judgment in variety of clinical settings, consensus guidelines were published in November 2016. In this article, the characteristics of these guidelines and related issues regarding the definitions of ‘the end stage of disease’ and ‘last days of life’ and the criteria for medical judgment are presented and summarized. According to the guidelines, the term ‘end stage of disease’ refers to a state in which there is no possibility of a fundamental recovery and the symptoms are expected to worsen within months. The terms ‘the last days of life’ and ‘the final days of life’ refer to a state in which, despite treatment, the patient's condition is worsening and death is impending, with no possibility of recovery. The attending physician and another relevant specialist should both judge a patient's medical condition as either ‘end stage of disease’ for hospice/palliative care or ‘the last days of life’ for dying patient care according to the law. Caregivers should provide appropriate medical information to eligible patients for palliative or ‘end stage of disease’ care through advance care planning. Therefore, it is critically necessary that caregivers understand the legitimate process of hospice/palliative and dying patient care based on the patient's wishes and best interests. Physicians should apply these consensus guidelines to eligible patients considering their clinical course and the patients' wishes.

A Possible Case of Statin-Induced Ichthyosis in an Elderly Woman / 가정의학회지

Ichthyosis is a heterogeneous group of hereditary or acquired skin disorders, characterized by increased stratum corneum production. Several systemic diseases and many drugs can occasionally cause acquired ichthyosis. We report a case of statin-induced ichthyosis in which the causality between statin and ichthyosis was found possible by using the Naranjo scale. A 79-year-old woman presented with pruritic skin lesions on both legs that appeared erythematous, scaly, and cracked. A clinical diagnosis of acquired ichthyosis was made and the statin was suspected as the cause. The skin lesions improved after 6 weeks of dose reduction of the statin.

Erratum: Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한구급학회지

The author's affiliation should be corrected. We apologize for any inconvenience that may have caused.

Symptom Features of Terminally Ill Cancer Patients and Depression of Family Caregivers / 한국호스피스완화의료학회지

PURPOSE: There has been very little study on the associations between patient's symptoms themselves and family caregiver (FC)'s depression in the palliative phase. This cross-sectional study was to investigate the relationship between symptom features of terminally ill cancer patients and their FC's depression. METHODS: We performed a multicenter survey using the MD Anderson symptom inventory and the Hospital Anxiety and Depression Scale. A total of 293 patient-FC pairs were recruited from seven tertiary medical centers. A multivariate regression analysis was applied for identifying the relevant factors associated with FC depression and for estimating adjusted depression score of FCs. RESULTS: Among various psychosocial factors, low FC quality of life, low social support, spouse, and more caregiving time were significantly associated with FCs' depression. According to the presence of FCs' depression, there were significant differences in some symptom characteristics of patients. Even after adjusting for the relevant confounders, depression scores were lower in FCs caring for patients who had negative symptoms (loss of appetite, P=0.005; drowsiness, P=0.024; and dry mouth, P=0.043) than in FCs caring for patients who had not. FCs caring for patients with severe appetite loss had lower depression scores than those with not severe one (P=0.039). CONCLUSION: Our result suggests that patient's symptom characteristics might be helpful when evaluating a FC's depression.

Correlation of Cardiovascular Risk Factors with Central Obesity and Multiple Body Mass Index in Korea / 가정의학회지

BACKGROUND: Body mass index (BMI) and waist circumference (WC) are associated with cardiovascular (CV) risk factors. The aim of this study was to investigate the correlation of CV risk factors by cross-tabulating central obesity with multiple BMI categories in Korea. METHODS: A total of 328,789 adults aged 30–84 years who completed health assessments for National Health Insurance in 2012–2013 in Korea were examined. The participants were divided into two WC and five BMI groups to investigate CV risk factors, including metabolic syndrome (MetS), hypertension, diabetes, and dyslipidemia. RESULTS: The proportions of central obesity and obesity were 24.2% and 39.5% in men and 19.4% and 28.1% in women, respectively, according to the Korean Society for the Study of Obesity and World Health Organization Asia-Pacific Guideline criteria. The odds ratios (ORs) of CV risk factors in all sexes increased with increases in BMI and WC. Compared to the group with a normal WC and BMI, the adjusted ORs (95% confidence intervals) for having MetS and diabetes in the centrally obese and highest BMI group (BMI ≥30.0 kg/m²) were 35.95 (33.75–38.30) and 3.51 (3.26–3.77) in men and 29.22 (27.36–31.20) and 4.35 (4.02–4.70) in women, respectively. Participants who were centrally obese and obese (BMI ≥25.0 kg/m²) had the strongest correlation with all CV risk factors compared with those who were not centrally obese or obese. CONCLUSION: The presence of central obesity in multiple BMI categories may significantly identify individuals at increased risk of CV risk factors.

Erratum: Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한중환자의학회지

The author's affiliation should be corrected. We apologize for any inconvenience that may have caused.

Factors Affecting Research Participation of Bereaved Families of Terminal Cancer Patients: A Prospective Preliminary Study / 한국호스피스완화의료학회지

PURPOSE: Little is known regarding the factors associated with the willingness of family caregivers of terminal cancer patients to participate in a bereaved survey. This study aimed to ascertain the pre-loss factors that predict actual participation in a bereaved survey. METHODS: We conducted a prospective observational study using data from two multi-center surveys at the end-of-life and after loss. In order to identify the pre-loss factors associated with participating in the bereaved survey, we used a step-wise multivariate logistic regression analysis. RESULTS: Among 185 bereaved individuals, 30 responded to the survey (response rate: 16.2%). There were differences between the participation group and the non-participation group regarding religion, economic status, and perceived quality of care as assessed by the Quality Care Questionnaire-End of Life. A final multivariate model revealed that bereaved individuals who professed a religion (adjusted odds ratio [aOR]=5.01; P=0.008), had a high income (aOR=4.86, P=0.003), and satisfied with the care for familial relationship (aOR=4.49, P=0.003) were more likely to engage in the bereaved survey. CONCLUSION: Our finding suggests that improving the quality of end-of-life care may promote actual participation in a bereaved survey through easing post-loss distress. More attention should also be paid to those bereaved individuals who are hesitant to participate in a bereaved survey.

Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한구급학회지

BACKGROUND: The aim of this study was to investigate the relationships between left ventricular ejection fraction (LVEF) and mortality and neurologic outcomes with post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA). METHODS: Patients with PCAS after OHCA admitted to the intensive care unit between January 2014 and December 2015 were analyzed retrospectively. RESULTS: total of 104 patients were enrolled in this study. The mean age was 54.4 ± 15.3 years, and 75 of the patients were male (72.1%). Arrest with a cardiac origin was found in 55 (52.9%). LVEF 55% was measured in 39 (37.5%), 18 (17.3%), and 47 (45.2%) of patients, respectively. In multivariate analysis, severe LV dysfunction (LVEF < 45%) was significantly related to 7-day mortality (odds ratio 3.02, 95% Confidence Interval 1.01-9.0, p-value 0.047). CONCLUSIONS: In this study, moderate to severe LVEF within 48 hours after return of spontaneous circulation was significantly related to 7-day short-term mortality in patients with PCAS after OHCA. Clinicians should actively treat myocardial dysfunction, and further studies are needed.

Moderate to Severe Left Ventricular Ejection Fraction Related to Short-term Mortality of Patients with Post-cardiac Arrest Syndrome after Out-of-Hospital Cardiac Arrest / 대한중환자의학회지

BACKGROUND: The aim of this study was to investigate the relationships between left ventricular ejection fraction (LVEF) and mortality and neurologic outcomes with post-cardiac arrest syndrome (PCAS) after out-of-hospital cardiac arrest (OHCA). METHODS: Patients with PCAS after OHCA admitted to the intensive care unit between January 2014 and December 2015 were analyzed retrospectively. RESULTS: total of 104 patients were enrolled in this study. The mean age was 54.4 ± 15.3 years, and 75 of the patients were male (72.1%). Arrest with a cardiac origin was found in 55 (52.9%). LVEF 55% was measured in 39 (37.5%), 18 (17.3%), and 47 (45.2%) of patients, respectively. In multivariate analysis, severe LV dysfunction (LVEF < 45%) was significantly related to 7-day mortality (odds ratio 3.02, 95% Confidence Interval 1.01-9.0, p-value 0.047). CONCLUSIONS: In this study, moderate to severe LVEF within 48 hours after return of spontaneous circulation was significantly related to 7-day short-term mortality in patients with PCAS after OHCA. Clinicians should actively treat myocardial dysfunction, and further studies are needed.

Unmet Medical Service Needs in Family Caregivers of Terminal Cancer Patients / 한국호스피스완화의료학회지

PURPOSE: The unmet medical service needs of caregivers critically influence their caring for terminal cancer patients, but not much research has been done in this regard. Thus, the purpose of this study is to investigate the association between caregivers' characteristics and their unmet medical service needs. METHODS: The survey was conducted with 109 family caregivers of terminal cancer patients admitted to four hospice units. The data were collected from March 2014 through December 2014 using a structured questionnaire. The unmet medical service needs were measured using 14 items which were adopted and modified by authors. RESULTS: Seven areas of unmet medical service needs were shown to be significant. A well-educated group showed stronger needs for counsel about cancer screening and complementary-alternative medicine and health supplement food. A never-smoked group was identified with less need for sexual dysfunction counsel. Counsel about family and personal relations was more necessary for current drinkers and current workers, and less necessary for the married. Insurance counsel was more needed for a no-religion group. Occupation counsel was less necessary for healthy patients. Financial support was less necessary for the married group. CONCLUSION: Based on the results, it is highly recommended to further investigate the unmet medical service needs of family caregivers for terminal cancer patients and causes of the unmet needs.

Factors Associated with Care Burden among Family Caregivers of Terminally Ill Cancer Patients / 한국호스피스완화의료학회지

PURPOSE: It is important to alleviate care burden for terminal cancer patients and their families. This study investigated the factors associated with care burden among family caregivers (FCs) of terminally ill cancer patients. METHODS: We analyzed data from 289 FCs of terminal cancer patients who were admitted to palliative care units of seven medical centers in Korea. Care burden was assessed using the Korean version of Caregiver Reaction Assessment (CRA) scale which comprises five domains. A multivariate logistic regression model with stepwise variable selection was used to identify factors associated with care burden. RESULTS: Diverse associating factors were identified in each CRA domain. Emotional factors had broad influence on care burden. FCs with emotional distress were more likely to experience changes to their daily routine (adjusted odds ratio (aOR), 2.54; 95% confidence interval (CI), 1.29~5.02), lack of family support (aOR, 2.27; 95% CI, 1.04~4.97) and health issues (aOR, 5.44; 2.50~11.88). Family functionality clearly reflected a lack of support, and severe family dysfunction was linked to financial issues as well. FCs without religion or comorbid conditions felt more burdened. The caregiving duration and daily caregiving hours significantly predicted FCs' lifestyle changes and physical burden. FCs who were employed, had weak social support or could not visit frequently, had a low self-esteem. CONCLUSION: This study indicates that it is helpful to understand FCs' emotional status and family functions to assess their care burden. Thus, efforts are needed to lessen their financial burden through social support systems.

The Prognostic Factors of Pneumonia with Septic Shock in Patients Presenting to the Emergency Department / 대한구급학회지

BACKGROUND: Pneumonia is the most common cause of death among patients with infectious disease in Korea. However, studies of pneumonia with septic shock in patients presenting to the emergency department are limited. The aim of this study was to investigate the prognostic factors associated with pneumonia with septic shock in patients presenting to the emergency department. METHODS: From January 2008 to September 2014, patients with pneumonia with septic shock admitted through the emergency department were retrospectively examined. RESULTS: Of the 561,845 patients who visited the emergency department, 398 were admitted for pneumonia with septic shock. The 28-day mortality rate in these patients was 36.4%. The independent prognostic factors were old age (>70 yrs) (odds ratio [OR], 2.42; 95%, confidence interval [CI], 1.35-4.32), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.04; 95% CI, 1.01-1.08), leukopenia (OR, 3.63; 95% CI, 1.48-8.94), prolonged PT-INR (OR, 2.53; 95% CI, 1.41-4.54), and hypoxemia (OR, 2.88; 95% CI, 1.30-6.38). CONCLUSIONS: A poor prognosis of patients with pneumonia is associated with old age (>70 yrs), increased APACHE II score, leukopenia, prolonged PT-INR, and hypoxemia.

The Prognostic Factors of Pneumonia with Septic Shock in Patients Presenting to the Emergency Department / 대한중환자의학회지

BACKGROUND: Pneumonia is the most common cause of death among patients with infectious disease in Korea. However, studies of pneumonia with septic shock in patients presenting to the emergency department are limited. The aim of this study was to investigate the prognostic factors associated with pneumonia with septic shock in patients presenting to the emergency department. METHODS: From January 2008 to September 2014, patients with pneumonia with septic shock admitted through the emergency department were retrospectively examined. RESULTS: Of the 561,845 patients who visited the emergency department, 398 were admitted for pneumonia with septic shock. The 28-day mortality rate in these patients was 36.4%. The independent prognostic factors were old age (>70 yrs) (odds ratio [OR], 2.42; 95%, confidence interval [CI], 1.35-4.32), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR, 1.04; 95% CI, 1.01-1.08), leukopenia (OR, 3.63; 95% CI, 1.48-8.94), prolonged PT-INR (OR, 2.53; 95% CI, 1.41-4.54), and hypoxemia (OR, 2.88; 95% CI, 1.30-6.38). CONCLUSIONS: A poor prognosis of patients with pneumonia is associated with old age (>70 yrs), increased APACHE II score, leukopenia, prolonged PT-INR, and hypoxemia.