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We report a case of refractory cancer pain that was successfully treated with opioid switching by adding methadone to the preceding opioid. A 38-year-old man had severe epigastric pain and back pain because of paraaortic lymph node metastasis of a gastroesophageal junctional carcinoma. His pain was treated with continuous intravenous morphine administration and the frequent use of a rescue dose. When the morphine dose was increased, respiratory depression developed; thus, his pain was considered refractory to the morphine, and methadone was added on. The pain was relieved after initiating methadone, and the frequency of the rescue dose was markedly decreased. The methadone dose was gradually increased in parallel, and the morphine dose was reduced and finally discontinued. No methadone-induced side effects were noted, and the patient was discharged with good analgesia. In our case, adding methadone without decreasing the preceding opioid dose under strict monitoring made it possible to stably switch the opioid without increasing pain.
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Background The number of foreign tourists visiting Japan has increased to about 30 million people per year. 1.5% of them were injured or became sick during their travelin Japan and had to undergo medical treatment. Among the foreign tourists, 27% were not covered by travel health insurance.Case A 40-year-old man from Southeast Asia who was visiting his relative in Japan experienced sudden hemiparesis and was diagnosed with cerebral infarction. During the initial treatment, it was found that the patient did not have health insurance and the relatives could not afford to pay the treatment costs. No other source of financial support was available to him During our consultations with the patient and his relatives about the medical treatment including medical expenses, he continued to be treated as an outpatient and it was aimed at an early return to his home country.Discussion Foreigners, who are not covered under travel health insurance, could fall ill or sustain an injury during their stay in Japan. Appropriate medical care should be provided regardless of their ability to pay. However, a situation that could lead them to incur huge medical expenses from availing medical care should be avoided. For medical consultations of non-insured foreigners, it is better to consult the available systems and pay attention about feasible medical expenses. There is a need for a long-term vision of medical care to make a smooth transition from medical treatment in Japan to treatment in their home country.Conclusion Although medical institutions can offer only a limited response, it is necessary to accumulate case examples from across the nation and prepare specific countermeasures and counselors.
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Objective: This study aimed to reveal the prevalence and characteristics of anguish among delirious patients with advanced cancer receiving specialized palliative care services. Methods: We conducted a subanalysis of a multicenter, prospective, observational study at 14 inpatient palliative care units and 10 general wards that offered psycho-oncology consultation service in Japan. We consecutively enrolled the patients with advanced cancer who were diagnosed with delirium and prescribed antipsychotics. Palliative care specialists decided whether patients suffered from anguish or not. We assessed patients’ background and severity of delirium with the Delirium Rating Scale-Revised (DRS-R-98). Results: Of 818 enrolled patients, 99 (12.1%) suffered from anguish. We observed a significant difference in the mean age (68.9±12.6 vs. 72.1±11.2, p=0.009), prevalence of dementia (2% vs. 10.4%, p=0.005) between patients with anguish and those without anguish. Patients with anguish had lower DRS-R-98 total scores before medication than those without anguish (15.3±8.1 vs. 17.3±7.8, p=0.018), but higher severity score in lability of affect (1.2±0.8 vs 1.0±0.9, p=0.023). Conclusions: The results of this study suggested that patients with anguish tend to be younger, mostly do not have dementia, and have lower delirium severity score but higher score in lability of affect. Nevertheless, further research, investigating appropriate evaluations and medical interventions for patients with anguish is warranted.
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Training system of palliative care in Japan has not been fully established, and young physicians’ needs for palliative care training are not nearly satisfied. We have recently conducted a nationwide survey to clarify unmet learning needs among Japanese physicians in specialty training in palliative care and the potential solutions they favored to meet those needs. Here we report findings of content analyses of free comments in the survey. Of 284 physicians, 253 (89%) responded, and 229 were eligible after we had excluded resident physicians with less than 2 years of clinical experience and board-certified palliative care physicians. The content analyses from 80 physicians (35%) identified 162 codes with respect to needs for improvement which were further classified into 24 subcategories and 9 categories (e.g., contents of subspecialty training, certified facilities, research capabilities, learning environment and methods, system of board certification, and networking). These findings may help improve specialty training in palliative care in Japan.
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Objectives: To explore background factors contributing to learning needs among physicians in palliative care specialty training. Methods: We conducted a questionnaire survey of physicians in specialty training in palliative care who were within 15 years after medical school graduation. The unmet learning needs (referred to as “needs”) were evaluated on a 5-point scale. Factor analysis was performed to identify underlying subscales of needs. Univariate analysis was performed using an average score of each subscale as a dependent variable and background factors as independent variables. Results: Of 284 physicians, 253 (89%) responded, and 229 were eligible after we had excluded resident physicians with less than 2 years of clinical experience and board-certified palliative care physicians. Factor analysis identified six subscales of the unmet learning needs: research, time, specialist, network, quality, and comprehensiveness. Background factors with significant between-group differences with the effect size of 0.4 or more included: 1) not working at a certified training facility, 2) not working or training at a big hospital, and 3) the number of palliative care physicians being 2 or less in the facility. Conclusion: Improvement of the training system is urgently needed for young physicians who are working at small or non-certified facilities for specialty training, or who have few palliative care colleagues.
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The aims of this study are 1. to evaluate the usability of workshop to introduce and manage distress screening effectively and efficiently and to use it for cancer patients and their family and 2. to consider the appropriate subject of workshop. All of the participants answered the questionnaire on the site (n=51). Their knowledge about screening practice, various screening tools and how to use screening tools and data from screening tool were significantly improved after the workshop. The workshop was highly regarded by participants. Thirty-eight of fifty-one patients responded to web questionnaire three months later (Response rate: 75%). More than thirty percent of participants put into practice what they learned in the workshop. The workshop decreased factors to interfere screening practice three months later. Knowledge about how to use screening tools was negatively correlated to number of cancer patients at hospital where participants worked and number of their hospital beds. And factor to interfere screening practice was negatively correlated to how long participants were involved in palliative care team. This study indicated the usability of workshop to spread screening triage program regarding cancer patients’ distress. The workshop may be appropriate for medical staffs who have relatively much experience of palliative care team and who have difficulty in screening practice at designated cancer hospitals where number of cancer patients is relatively large.
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Methadone, which has unique mechanism of long-acting mu receptor agonism paired with N-Methyl-D-Aspartate（NMDA）antagonism, is thought to have potential to control pain no longer responsive to other opioids. Fatal adverse effects of methadone are respiratory suppression and QT interval prolongation, which leads to ventricular tachycardia. Here we report a case of a patient who benefited from starting on methadone in hospital and increasing methadone safely in a home-based care setting. A 79-year-old Japanese woman, who developed local recurrence after resection for primary retroperitoneal leiomyosarcoma, presented with frequent burning pain in right groin area. After receiving palliative radiation therapy, she took oxycodone and adjuvant analgesics but without relief, and began experiencing somnolence. She underwent opioid switching from oxycodone to methadone with her breakthrough pain remarkably improved. When her breakthrough pain recurred after discharge, escalating dosages of methadone was performed successfully with no serious adverse effects even in a home-based care setting, by forming multidisciplinary collaboration for the management of prescribing methadone among healthcare providers near her home.
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We report a case of successful treatment for bladder hemorrhage with intravesical alum irrigation. A 60 s woman, who had renal pelvis carcinoma and moderate renal dysfunction（eGFR＝48 mL／min／1.73 m<SUP>2</SUP>）, was hospitalized to our palliative care unit, for pain control of her lumber metastasis. During hospitalization, the patient showed dysuria and a lot of intravesical blood coagulum, which was caused from bladder metastasis. After bladder flushing, continuous bladder irrigation with saline was started. However, when we reduced the irrigation speed, dysuria appeared again. Thus, we started intravesical alum irrigation. Six days after this irrigation has started, we stopped the irrigation because no gross hematuria was seen any more. On the blood test done ninth day after irrigation, serum alminium level was 0.4μg／dL（normal value＜0.8μg／dL）. Three months after discharge from the hospital, the patient died, however, no gross hematuria or anuria were seen up to that time. Serious adverse effects with intracesical alum irrigation were reported in patients with renal dysfunction. However, if the renal dysfunction was moderate, intravesical alum irrigation with reduced doses seem to be safe and effective.
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<b>Background</b>: 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. <b>Methods</b>: 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. <b>Results</b>: 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. <b>Conclusion</b>: 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 aim of this study was to explore the changes in the rates of discharge to home from the palliative care unit in the region where the regional palliative care intervention program, their home death rate, and their ratio to whole home death cancer patients in the region. During the study period, the palliative care unit changed an administrative policy actively end-of-life care to support patients at home. The rate of discharge to home from the palliative care unit increased 11% to 22% during the study period, and their home death rate increased 10% to 41%. The overall home death rate of cancer patients however remained 6.8% to 8.1%, and their ratio to whole home death cancer patients in the region was less than 10%. To establish health care system to support cancer patients at home, changing administrative policy of palliative care units is insufficient and increasing quality community palliative care resources seems to be essential.