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Abstract: We report a case of acquired hemophilia A diagnosed after hospitalization in a palliative care unit. Case: The patient was an 86-year-old man diagnosed with gastric carcinoma one-year prior, who declined treatment but whose progress was being monitored. He was admitted to our hospital due to multiple, systemic, and subcutaneous bleeding and exacerbation of anemia. Blood testing revealed prolonged activated partial thromboplastin time (APTT), but the cause was unknown. Subcutaneous bleeding persisted after hospitalization, accompanied by pain. After admission to a palliative care unit, blood testing revealed only prolonged APTT; hence, a coagulation study was performed, resulting in a diagnosis of acquired hemophilia A. Immunosuppressive therapy was considered but was not performed as the patient’s progress was complicated by aspiration pneumonia for which antibiotics were ineffective, and the patient’s prognosis was determined to be short. The patient died on the 20th day after admission to the palliative care unit. Conclusion: Acquired hemophilia A is a rare hemorrhagic condition, but it is important to suspect it in cases involving prolonged APTT and spontaneous bleeding with no medical history or family history.
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Background： While the number of older cancer patients increases as the society ages, the current status of the pain control is not well characterized among older patients. To improve the quality of care, it is necessary to understand the current status. Objectives： The aim of this study was to describe the pain control for older cancer patients in comparison to younger counterparts and characterize it. Methods： During four months in 2013, Aomori Prefectural Central Hospital started asking all hospitalized cancer patients about their pain every day using a standardized pain questionnaire. In addition, a questionnaire adopted to the outpatient setting was distributed to the patients who visited outpatient department of the hospital. The information about pain, quality of life (QOL) and the medical histories were included in the data analyses. Their responses were compared between outpatients versus inpatients and older ( ≥65 years) versus younger (＜65 years) patients. Results： The response rate was 57.0％. Pain management was less adequate among outpatients than among inpatients, with pain relief rate of 28.9％ for the former and 52.6％ for the latter (P＜0.001). Among outpatients, the pain relief rate for the older patients was particularly low (older：24.7％ vs younger：35.8％, P＜0.01). Conclusion： Pain management for older patients in the outpatient settings needs a particular attention for improvement. Resources should be allocated to enable better detection and relief of pain among outpatients.
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Methadone oral tablets initially became available on the Japanese market in MAR－2013. Methadone, which has different pharmacological properties from other opioids including morphine, can cause serious adverse drug reactions such as respiratory depression and QT prolongation. One of the causes of these reactions is its extremely complex pharmacokinetics. Methadone is mostly metabolized in the liver, with a variety of metabolic enzymes, including cytochrome P450 (CYP) 3A4, CYP2B6, and CYP2D6, being involved. The characteristics of methadone include self-induction of metabolism, delayed excretion due to alkaline urine, and an extremely long half-life requiring a long time to achieve a steady state. Without a full understanding of its complex pharmacokinetics, the blood concentration of methadone is not maintained at a constant level, and serious adverse events could happen due to an unexpected increase in its blood concentration. Herein, for safe clinical use by physicians and pharmacists, we summarize the pharmacokinetics of methadone.
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Since bibliographic items had an error, it corrects as follows. <BR><BR>p.158, upper right of a page<BR>(Error) Palliative Care Research 2012; 8(1): 158-67<BR>(Correct) Palliative Care Research 2013; 8(1): 158-67<BR><BR>p.158, center of a page<BR>(Error) Palliat Care Res 2012; 8(1): 158-67<BR>(Correct) Palliat Care Res 2013; 8(1): 158-67<BR><BR>p.164, center of a page<BR>(Error) Palliat Care Res 2012; 8(1): 158-67<BR>(Correct) Palliat Care Res 2013; 8(1): 158-67
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<b>Purpose</b>: The research is aimed at the evaluation of management of pain in elderly cancer patients receiving home-based care. <b>Methods</b>: 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. <b>Results</b>: 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 (<i>p</i>=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 (<i>p</i><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 (<i>p</i><0.0001). <b>Conclusion</b>: 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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This is a report on a case of delirium due to a small amount of ketamine with voriconazole. A 58 year old male was treated for multiple myeloma and hip pain due to an extramedullary tumor following the administration of oxycodone, and voriconazole was administrated for his suspected mycotic pneumonia. His pain was refractory, so we started the administration of a small dose of ketamine (4 mg/hr) for analgesia, added to oxycodone. About 30 hours later, the delirium appeared but he complained of worsening hip pain, so we added 2 mg of ketamine rapidly. Immediately after the additional administration of ketamine, his delirium became more serious. We think the reason why a small amount of ketamine induced delirium is an interaction of ketamine and voriconazole. Ketamine is metabolized to norketamine, which is thought to be more harmless than ketamine, by cytochrome P 450 (CYP) (a part of by CYP3A4) and voriconazole is an inhibitor of CYP3A4. In cases of patients treated with voriconazole, ketamine should be more carefully administrated.
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It is important to collect patients' and their families' opinions to provide good palliative care. This study aims to analyze the contents of free description provided by the survey for cancer patients and bereaved families, which was performed before the intervention of The Outreach Palliative Care Trial of Integrated Regional Model (OPTIM) study. Requests for and good points of cancer treatment and palliative care were collected and classified. 1,493 advanced cancer patients and 1,658 bereaved families in four areas received the questionnaire, and 271 patients and 550 families filled in the free description. Cancer patients and bereaved families had demands for improved communication with medical staff, improved quality of pain relief, financial support of treatment, more educational activities on palliative care, and improved cooperation within and outside hospitals. Palliat Care Res 2011; 6(2): 237-245
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<b>Purpose</b>: Palliative care is an essential part of integrated cancer treatment. This study aimed to identify general practitioner (GPs)' perceptions of palliative care and the difficulties they encounter in providing care to terminally ill cancer patients. <b>Methods</b>: Japanese GPs in a rural area where palliative care resources were inadequate were surveyed by questionnaire. Using the questionnaire, researchers visited 62 clinics in the area and carried out semi-structured interviews to identify problems and to investigate possible ways to promote the provision of palliative care by GPs. The transcripts were manually coded into descriptive and interpretive categories. <b>Results</b>: Seventy seven out of 95 responded to the questionnaire (effective response rate: 81%). Experience of pain control was inversely related to the extent of the GPs' perceived difficulties in providing palliative care. Lack of hospital support and understanding of patients and their families were also barriers to the provision by the GPs of palliative care to terminally ill cancer patients at home. The suggested solutions were: to provide seminars for doctors in the area to improve their pain control and other clinical skills; to build up good relations between the doctors in hospitals and clinics in the area; and to educate patients, families and the community at large in the necessity of palliative care. <b>Conclusion</b>: Our study indicated that building up good inter-organizational relations among physicians and educating the community were important in order to promote GPs' participation in palliative care. Palliat Care Res 2009; 4(2): 112-122
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<b>Purpose</b>: In Japan, the daily dosage limit of acetaminophen is considered to be 1500mg: however, in Europe and the USA, the daily dosage limit of acetaminophen for patients with cancer pain is 4000 mg. In Japan, only 100 mg and 200 mg acetaminophen suppositories are available, which means that cancer pain patients may need to insert up to 3 - 4 acetaminophen suppositories at the same time. Therefore, in this study, we examined the efficacy of 600 and 800 mg suppositories prepared at our hospital. <b>Methods</b>: We measured the serum concentrations of acetaminophen in cancer pain patients prescribed either oral or the rectal formulation of acetaminophen, and examined the side effects of the drug. <b>Results</b>: Our results revealed similar mean blood concentrations of acetaminophen in both the oral and rectal group of patients, and the serum AST, ALT and total bilirubin levels were within normal range in all the cancer pain patients prescribed acetaminophen. <b>Conclusion</b>: Our results suggest good bioavailability of acetaminophen from the acetaminophen suppositories in our cancer pain patients.