A Case of Acute Withdrawal Symptoms Due to Unplanned Interruption of Buprenorphine Transdermal Patch: With a Discussion Including Social Aspects of Home Medical Care Patients

Introduction: Since the commercial availability of buprenorphine extended-release transdermal patches (BTDP) from the early 2010’s, the therapeutic indications for opioids have widely expanded to include chronic benign diseases. We report a case of a home health care patient with acute opioid withdrawal symptoms due to self-interruption of BTDP. Case: An 84-year-old man using home health care services due to worsening of lumbar spinal canal stenosis had been receiving analgesia with a BTDP, a mixed opioid agonist/antagonist analgesic, for the preceding five months. Since the patient's spouse thought that his pain and symptoms were gradually improving, she secretly replaced the BTDP with an NSAID patch without informing the patient. About 50 hours later, the patient experienced a variety of symptoms, including frequent urination with incontinence every five minutes, watery diarrhea, sweating, decreased blood pressure, discomfort in the feet, and insomnia. Evaluation of the Clinical Opiate Withdrawal Score (COWS) by the home health care physician indicated a score of 12, corresponding to mild withdrawal symptoms. About 12 hours after symptom onset, the severe abnormalities were barely noticeable and completely disappeared after two days. Conclusion: Few previous case reports have described withdrawal symptoms due to rapid discontinuation of BTDP. In addition to the medical considerations, we report the social issues associated with onset of the condition in a home environment. Opioid use for non-cancer pain requires medication management from a different perspective than that for cancer pain.

A Case Where the Epidural Block Was Useful for the Differential Diagnosis of Low Back Pain in a Patient with Esophageal Cancer and Lumbar Disc Herniation

Introduction: We experienced a case in which an epidural block was useful in estimating the cause of low back pain in a patient suffering from esophageal cancer with liver and paraaortic lymph node metastases. Case: A 69-year-old male with a history of surgery for lumbar disc herniation (at the age of 20). He was diagnosed with esophageal cancer and during follow-up, he noticed low back pain, followed by epigastric pain. MRI revealed L1/2 and L2/3 intervertebral disc herniation. The thoracic epidural block was performed from Th8/9 under X-ray fluoroscopy to alleviate symptoms and identify the cause of low back pain. After confirming the analgesic effect, we conducted a splanchnic nerve block using neurolytic agent (anhydrous ethanol), resulting in total pain elimination. Subsequently, the patient passed away under good pain control without increasing the dose of analgesics. Conclusion: By confirming the effectiveness of epidural block at the thoracic level in advance, the complicated pain was thought to be derived from not lumber disc herniation, but the visceral nerves. An epidural block was useful for the selection of subsequent analgesic therapy.

Feasibility, Surface and Content Validity of the Integrated Palliative care Outcome Scale (IPOS) for Non-cancer Patients

Purpose: To examine the feasibility of the Integrated Palliative care Outcome Scale (IPOS), a comprehensive palliative care scale, for non-cancer patients. Methods: Twenty non-cancer patients and 20 healthcare providers who provide care to the participating patients were asked to complete the IPOS questionnaire, and cognitive interviews were conducted with them. The interviews were analysed using content analysis, a qualitative analysis method. Results: About half to 90% of both patients and healthcare providers answered that they did not find it difficult to answer or understand all items of the IPOS. Therefore, we confirmed its surface validity, and the content validity of the IPOS was confirmed. Conclusion: The surface validity and content validity of the IPOS for non-cancer patients were confirmed, and it became clear that the IPOS can be used as a comprehensive assessment tool for the palliative care of non-cancer patients.

Actual Usage of a Pamphlet for Families of Terminally Ill Patients With or Without Cancer at Home

Objective: The purposes of this study were to explore the actual usage of a pamphlet for families of terminally ill patients both with and without cancer at home. Methods: We sent a questionnaire to 2,000 home-visit nursing administrators and obtained answers from 430. This study included 224 pamphlet users. Results: The pamphlet was used with 95.1% of families of cancer patients and with 76.8% of families of non-cancer patients. Most pamphlet users were concerned with the following: degree of worry and anxiety of the family, and the family’s and the patient’s hope for an at home death (families of both cancer patients and non-cancer patients more than 84%). The pamphlet was given to about 60% of families of both cancer patients and non-cancer patients between last last week and last month of life. Administrators found it difficult to decide the appropriate timing to hand out the pamphlet to 59.6% of families of cancer patients and 69.7% of families of non-cancer patients. Conclusion: Pamphlet use may be improved by clarifying the appropriate timing to give out the pamphlet.

Prescribing Opioids for Chronic Pain / 신경정신의학

Opioids are effective analgesics, but they are often difficult to use properly, due mainly to adverse events, such as constipation, respiratory depression, addiction, tolerance, and opioid induced hyperalgesia. In the past, the problem of opioids around the world was usually caused by drugs traded illegally, so there was no need for medical and social attention in Korea. On the other hand, with the dramatic increase in the therapeutic use of opioids, which commenced more than a decade ago, problems caused by legally prescribed drugs have emerged, and now a more serious opioid crisis is being experienced than in the days of illegal drugs. A growing number of patients are chronically prescribed opioids, and a growing number of health care providers and hospitals suffer from problems related to chronic prescription. Currently, in Korea, it is the time to pay serious attention to achieve the safe and effective use of prescribed opioids. This paper consists of the following parts. 1) A summary of the issues related to chronic pain, opioids, and problems associated with the use of opioids. 2) Some case examples the authors' experienced. 3) Simple guidelines on the use of opioids in the treatment of chronic non-cancer pain are proposed based on the author's experience and existing literature. These guidelines are by no means comprehensive, and hopefully in the future, related experts will join forces to develop better guidelines.

Overview of the Management of Chronic Non-Cancer Pain in Patients with Spinal Disease

STUDY DESIGN: Cross-sectional, multi-center survey study. OBJECTIVES: The objective of this study was to investigate the pain status, pain management methods, and pain experience after treatment among patients suffering from chronic non-cancer pain due to spinal disease. SUMMARY OF LITERATURE REVIEW: No thorough investigation of the current status of chronic non-cancer pain management in patients with spinal disease has recently been reported. MATERIALS AND METHODS: We surveyed 330 patients with chronic non-cancer pain who visited spine clinics in Korea. RESULTS: Prior to treatment, 86.7% of the patients had severe pain and 99.4% of the patients had taken oral analgesics for pain control. After treatment, the percent of patients with severe pain was reduced to 42.1%, and 52.4% of patients responded that they experienced intermittent pain. End of dose failure was experienced by 29.1% of patients, and 41.7% of patients experienced pain again 3–6 hours after taking analgesics. Furthermore, 8.2% of patients experienced breakthrough pain, and 29.1% of patients experienced pain that interfered with sleeping. CONCLUSIONS: Many patients with chronic pain reported experiencing pain due to end of dose failure after medication. As the causes of chronic pain are complex, appropriate analgesics should be considered and selected for effective pain management.

Retrospective Study of Prognostic Prediction Based Only on Objective Indicators in End-of-life Patients: A Study Using Biological Prognostic Score Version-2

Objective: We retrospectively studied the adaptation and limits of applying Biological Prognostic Score Version-2 composed only of blood test results to prognostic prediction in end-of-life non-cancer patients. Methods: The prognostic score was calculated from the cholinesterase, blood urea nitrogen, and white blood cell counts of hospitalized end-of-life non-cancer patients, divided into three groups with cutoff values, and prediction accuracy analysis, survival analysis, and simple regression analysis were performed. Results: Diagnostic accuracy of 204 non-cancer patients at the same cut-off value and predicted survival time as cancer was 79% accurate at 3 weeks survival and 63% at 9 weeks. Specificity and negative predictive value were highly accurate, sensitivity and positive predictive value were low. In the survival analysis, the discrimination between the 3 groups was significant (p<0.05), but the regression coefficient in the regression analysis was not significant (p=0.43). Conclusion: The prognostic prediction using this score for non-cancer patients has high prediction accuracy in the case of good prognosis. It is suggested that clinical use of this score is also possible if used cautiously.

The Current Status of Palliative Care for Non-cancer Patients in Japan: Field Survey on the Representatives of the Japanese Society for Palliative Medicine

Purpose: The field survey was conducted to evince the current status of palliative care for non-cancer patients. Methods: The on-line questionnaire survey was conducted covering 196 representatives of the Japanese Society for Palliative Medicine. Multiple-choice questions were asked about their medical experiences with non-cancerous diseases, their attitudes towards palliative care, their feelings of bewilderment upon providing palliative care, and what they thought would be required for future education in this field. Results: One-hundred and eleven (111) representatives (57%) responded the survey. Ninety-nine (99)% of the respondents experienced providing non-cancer patients with palliative care, but 63% of them experienced less than 50 patients in the terminal phases even in cumulative total. Eighty (80)% of them said they were feeling insecure about providing non-cancer patients with palliative care, and 83% of them were feeling difficulty when they had to do so. The reasons listed included that prognostic prediction for such cases wouldn’t be easy and that it wouldn’t be covered by public health insurances. What they felt necessary about future education included communication and multi-disciplinary team medicine, in this order. Conclusions: The representatives of the Japanese Society for Palliative Medicine are well-aware of the demands for palliative care for non-cancer patients, but not many of them have experienced such cases and more than 80% of them are feeling insecure and difficulty about providing it.

Safety Assessment of Peripherally Inserted Central Venous Catheter: A Retrospective Single-center Study to Compare Cancer and Non-cancer Patients

<p>Objectives: Peripherally inserted central venous catheter (PICC) is widely used, because the incidence of complications and bloodstream infection in patients receiving PICC was lower than that in patients receiving central venous catheter. We compared PICC between cancer patients and non-cancer patients. Methods: This retrospective single-center study included 157 patients receiving PICC from May 2012 to September 2015. Patients were separated into cancer and non-cancer groups. Results: Cancer patients were 88 and non-cancer patients were 69. The most common causes of PICC were intravenous hyperalimentation (Cancer vs. non-cancer: 45 vs. 51) and difficult peripheral venous access (40 vs. 12) (p=0.0022). The duration of catheterization was 15 (6-39) vs. 21 (12-40) days (p<0.0001). The causes of catheter removal were death (50 vs. 14), remission (9 vs. 26), redness on insertion site or infection suspicion (10 vs. 11), and Some kind of catheter trouble (8 vs. 4) (p=0.0002). Complications occurred in 8 vs. 9 patients (p=0.429), and infection occurred in 0.9 vs. 2.0/1000 catheter days (p=0.041). Discussion: End-stage cancer patients have a weakened immune system. In this study, the incidences of PICC-related infection and other complications were not different between cancer and non-cancer patients, suggesting PICC was a safer method.</p>

Hospice and Palliative Care in Chronic Obstructive Pulmonary Disease / 한국호스피스완화의료학회지

Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive. It is a major cause of morbidity and mortality worldwide, leading to substantial and increasing economic and social burden. Palliative care for COPD patients aims to reduce symptoms and exacerbations and improve exercise tolerance and quality of life. It is difficult to make a prognosis for COPD patients due to the variable illness trajectory and advanced care of patients. However, severity of breathlessness, assessment of lung function impairment, and frequency of exacerbations can help to identify palliative care needs and determine effective methods to mitigate symptoms, which is discussed in this paper. In these patients, it is recommended to provide individualized palliative care along with curative/restorative care at the onset of COPD symptoms. Before launching a palliative care system in Korea, it is necessary to prepare pulmonary rehabilitation resources, patient-centered communication, timely palliative responsiveness, and a program for effective advanced care planning. A multidisciplinary approach involving collaboration with not only the respiratory and palliative care teams but also primary care offers a new model of care for these patients and should be considered with a priority.

Guidelines for prescribing opioids for chronic non-cancer pain in Korea

As the treatment of chronic non-cancer pain gradually increases, clinicians have more opportunities to encounter opioid prescription. However, guidelines for prescribing opioids for chronic non-cancer pain have never been published in Korea. The present guidelines were prepared by reviewing various research data. In cases in which the data were insufficient, recommendations were presented following discussion among experts affiliated with the Opioids Research Group in the Korean Pain Society. The present guidelines may need to be continuously revised and amended as more clinical evidence is acquired.

Clinical Usefulness of Long-term Application of Fentanyl Matrix in Chronic Non-Cancer Pain: Improvement of Pain and Physical and Emotional Functions

BACKGROUND: Opioids are recently recommended for those who do not gain adequate pain relief from the use of acetaminophen or nonsteroidal anti-inflammatory drugs. Medical opioids are administered in various routes, and transdermal opioid products that can make up for the weaknesses of the oral or intravenous products have been developed. This study is to evaluate the clinical usefulness of fentanyl matrix in terms of the long-term improvement in pain and physical and mental functions. METHODS: This was a multicenter, open, prospective, observational study that was conducted in 54 institutions in Korea. Patients with non-cancerous chronic pain completed questionnaires, and investigators also completed questionnaires. A total of 1,355 subjects participated in this study, and 639 subjects completed the study. Subjects received transdermal fentanyl matrix (12 µg/hr, 25 µg/hr, or 50 µg/hr depending on the patient's response and demand). Subjects visited at 29 ± 7 days, 85 ± 14 days, and 169 ± 14 days after administration, respectively, to receive drug titration and fill out the questionnaires. The results were analyzed using the intention-to-treat (ITT) analysis, full analysis set (FAS), and per-protocol (PP) analysis. The FAS analysis included only 451 participants; the PP analysis, 160 participants; and the ITT analysis, 1,355 participants. RESULTS: The intensity of pain measured by the Numeric Rating Scale decreased from 7.07 ± 1.78 to 4.93 ± 2.42. The physical assessment score and mental assessment score of the Short-Form Health Survey 12 improved from 28.94 ± 7.23 to 35.90 ± 10.25 and from 35.80 ± 11.76 to 42.52 ± 10.58, respectively. These differences were significant, and all the other indicators also showed improvement. Adverse events with an incidence of ≥ 1% were nausea, dizziness, vomiting, and pruritus. CONCLUSIONS: The long-term administration of fentanyl matrix in patients with non-cancerous pain can reduce the intensity of pain and significantly improves activities of daily living and physical and mental capabilities.

Identification of prognostic predictors in critically ill non-cancer patients without severe organ failure in a medical long-term care ward / 日本プライマリ・ケア連合学会誌

<b>Introduction</b> : The aim of this study was to identify prognostic predictors in critically ill non-cancer patients without severe organ failure in a medical long-term care ward.<br><b>Method</b> : We retrospectively studied 36 non-cancer patients who died in our ward between October 2011 and March 2014. All patients were bedridden with mild impairment of consciousness, were unable to consume food or water, but had no severe organ failure. We attempted to identify the factors that significantly affected their prognosis.<br><b>Result</b> : Mean age was 85 years and the male to female ratio was 19 : 17. Diagnoses were dementia (21cases), senility (8 cases), Parkinson's disease (4cases) and multiple cerebral infarctions (3 cases). Median survival time after subcutaneous drip infusion was 31days. No significant prognostic factors were identified by correlation and multivariate regression. Prognosis for patients who had serum albumin levels under 3mg/dl, however, was worse than in patients with levels above 3mg/dl (27 days vs 61 days , p=0.001).<br><b>Conclusion</b> : We were unable to identify clear prognostic predictors in this study. Serum albumin levels, however, may influence prognosis in critically ill non-cancer patients without severe organ failure.

A Study on Application of Inhalation Risk Assessment Model of USEPA in Occupational Health Risk Assessment / 预防医学

Objective To evaluate the applicability of inhalation risk assessment model provided by US Environmental Protection Agency (USEPA ) in occupational health risk assessment in paper -making,chemical and electroplating industries.Methods A total of 1 1 factories in paper-making,chemical and electroplating industries were investigated. The risk assessment model of USEPA was used to assess occupational health risk levels,including cancer and non-cancer risks.These results were compared with occupational exposure limits,classification of occupational hazards and related literatures.Results The hazard quotient (HQ)of nasal lesions of the olfactory mucosa caused by hydrogen sulfide in paper-making industry was 36.3.The HQs of hyperplasia of nasal mucosa larynx and trachea caused by hydrogen chloride and cerebellar lesions caused by methyl chloride in organosilicon synthesis factory were 8.2 and 1.4 respectively.The HQs of decreased pulmonary function or increased severity of rhinitis and pneumonia caused by ammonia in pesticide factory were 1.2 and 1 .5 respectively.The HQ of impaired motor coordination caused by xylenes in chemical solvent factory was 2.4. The HQs of hyperplasia of nasal mucosa larynx and trachea caused by hydrogen chloride and nasal septum atrophy caused by hexavalent chromium in electroplating industry were 2.3-75.3 and 1 92.5 -25 675 respectively .The risk levels of paper-making,chemical and electroplating industries were all identified as high on the basis of evidence showing that HQs were all higher than 1 .The risk of lung cancer caused by hexavalent chromium in electroplating industry was 0.001 -0.1 647.The results of risk assessment were consistent with the reported literature.Conclusion Inhalation risk assessment model provided by USEPA can be used to assess the occupational health risks of paper -making, chemical and electroplating industries and have better identification ability.

Validación primera encuesta chilena de dolor crónico no oncológico / Chilean validation survey of chronic non cancer pain

Existen escasos estudios sobre prevalencia de dolor crónico no oncológico en nuestro país. Objetivo: Realizar y presentar un instrumento validado que permita estimar la prevalencia y el impacto del dolor crónico no oncológico en Chile. Método: Se diseñó un instrumento basado en European Survey of Pain, Pain Survey U.S. Population, Canadian Chronic Pain Survey y la Encuesta Prevalencia de Dolor de la Federación Latinoamericana de Dolor. Se realizó una encuesta sobre teléfonos móviles, en un estudio piloto, en una muestra probabilística representativa a nivel nacional de 20 sujetos, mayores de 18 años de edad. Resultados: Se realizó un instrumento validado de 27 secciones, en el cual se determinó una prevalencia de 30,2 (IC95 por ciento: 22,5 – 37,4). Conclusiones: Presentamos un instrumento validado con el objetivo de determinar la prevalencia y las características clínicas del dolor crónico no oncológico a nivel chileno...

There are few studies on the prevalence of chronic non-cancer pain in our country. Aim of Investigation: To make and present a validated instrument that will allow to estimate the prevalence and impact of chronic non-cancer pain in Chile. Methods: We designed an instrument based on the European Survey of Pain, the US Population-Based Pain Survey, the Canadian Chronic Pain Survey and the Latin American Federation of Pain Prevalence Survey. A cross sectional cell phone survey was conducted in a pilot study in a nationally representative probability sample of 20 subjects, over 18 years old. Results: We made a validated instrument of 27 sections, the prevalence of chronic non-cancer pain was 30.2 (95 percent CI 22.5 - 37.4). Conclusions: We present a validated instrument to determine the prevalence and clinical characteristics of non-cancer chronic pain in Chilean people...

Non-cancer Diseases of Korean Atomic Bomb Survivors in Residence at Hapcheon, Republic of Korea

Many Koreans, in addition to Japanese, were killed or injured by the atomic bombs detonated over Hiroshima and Nagasaki, Japan, in 1945. Our study examined noncancer diseases of Korean A-bomb survivors in residence at Hapcheon, Republic of Korea and evaluated whether they had significantly higher prevalence of noncancer diseases than non-exposed people. We evaluated a number of tests, including anthropometric measurements, blood pressure, blood chemistry, hepatitis B surface antigen, and urinalysis, of survivors (n=223) and controls (n=372). Univariate analysis revealed significantly lower fasting glucose and creatinine, and higher diastolic blood pressure, aspartate aminotransferase, alanine aminotransferase, and blood urea nitrogen levels in the survivors than in the controls. The calculation of crude prevalence ratios (PRs) revealed that A-bomb survivors had a significantly higher prevalence of hypertension (PR, 1.16; 95% CI, 1.00-1.35) and chronic liver disease (2.20; 1.59-3.06) than controls. After adjusting for covariates (age, sex, body mass index, marital status, education, alcohol consumption, and smoking), A-bomb survivors had a significantly higher prevalence of hypertension (1.24; 1.06-1.44), chronic liver disease (2.07; 1.51-2.84), and hypercholesterolemia (1.79; 1.11-2.90) than controls. This study suggests that A-bomb exposure is associated with a higher prevalence of non-cancer diseases in Korean survivors.

Nutritional Status of Cancer Patients upon Admission / 간호학회지

The purpose of this study was to assess the nutritional status of cancer patients and non-cancer patients who were admitted to an internal medical department and to determine the degree of malutrition among these patients. The study was performed from May to July 1996 with 151 subjects recruited from the general medical department at D University Hospital. For nutritional assessment the anthropometric and biochemical assessment were performed. Biochemical measurements included serum hemoglobin, albumin, and lymphocytes. For anthropometric assessment, patient's body weight, skinfold thickness in four areas, body mass index, and percent of body fat were measured. The results were as follows : 1) Of the 151 patients who were studied, 47 patients had cancer while 104 patients had non cancer related disease. The mean age of the cancer patients was 57 and 52 for non cancer patients. The percentage of patients who had lost body weight during the last 6 months was 29.8% in cancer patients and 15.4% in non cancer patients. This percentage difference between the 2 groups was statistically significant. However, there was no statistical significance between the 2 groups in gastrointestinal symptoms which lasted more then 2 weeks. 2) There was a statistically significant difference in nutritional status(lympocyte : p=.002 ; skinfold thickness in four areas : p<0.05) between the cancer and the non-cancer patients. The percentage of the patients who had the possibility of malnutrition was 65.5% in cancer patients and 6% in non-cancer patients. 3) There was correlation between the weight loss during the last 6 months before admission and body mass index and skinfold thickness.

Ethical Reflection on the Therapy of Chronic Non-Cancer Pain / 中国医学伦理学

Aim to solve the common problems in the chronic non-cancer therapy,the author proposed that the medical professional ethics should be strengthened,and both the right and obligation of patient and doctor should be respected.The ethical issues in the psychological treatment as well as the use of opium drug and advanced technique are analyzed in the paper.