Identifying the unmet physical and psychological intimacy and sexual needs of partners of patients with terminal cancer.

BACKGROUND: Palliative care aims to improve the quality of life of patients who are terminally ill, but support for the sexuality of these patients is often inadequate. AIM: To identify factors related to the unmet needs of bereaved partners whose significant others died of cancer during hospitalization. METHODS: Bereaved individuals in Japan aged >50 years who had lost their partners to cancer in a hospital in the last 5 years answered a questionnaire on the support desired for "time to nurture love with your partner." OUTCOMES: We used 3 sexual questions in the 34-item Supportive Care Needs Survey-Short Form (SCNS-SF34) and measured the unmet needs of partners of patients with terminal cancer. RESULTS: We obtained 290 responses (equal number of males and females). Respondents' age distribution was as follows: 50 to 59 years, 34.8%; 60 to 69 years, 44.5%; 70 to 79 years, 19.3%; ≥80 years, 1.4%. In total, 81% had children. Most partners died in the general ward (59.3%). Frequency of time to nurture love with one's partner before the illness was as follows: none at all, 44 (15.2%); very little, 84 (29.0%); once in a while, 76 (26.2%); occasionally, 45 (15.5%); and often, 41 (14.1%). Roughly 20% of participants reported experiencing unmet sexual needs across all 3 selected questions in the SCNS-SF34. Multivariate analysis showed that younger age (P = .00097) and a higher frequency of time to nurture love with one's partner before illness (P = .004) were positively associated with unmet needs for sexuality during hospitalization. CLINICAL IMPLICATIONS: The study may help health care workers identify patients who are seeking sexual support. STRENGTHS AND LIMITATIONS: This study identified the unmet needs and underlying factors regarding sexuality during hospitalization for partners of patients with terminal cancer. However, differences by cancer type could not be analyzed. Additionally, the modified version of the supportive care needs measure used in this study (SCNS-SF34) may have decreased validity owing to the alterations made for its use. CONCLUSION: Some hospitalized patients with terminal cancer could need support for time to nurture love with their partners. Health care providers can play a crucial role by anticipating the needs of patients, preparing them mentally, and offering counseling and information to help them maintain an intimate connection with their loved ones.

Development of a list of competencies and entrustable professional activities for resident physicians during death pronouncement: a modified Delphi study.

BACKGROUND: The appropriate delivery of death pronouncements potentially affects bereaved families' wellbeing positively. Although younger physicians need to learn the competencies and entrustable professional activities (EPAs) to conduct death pronouncement independently, both of which have not been clarified. Therefore, this study aimed to develop a list of competencies and EPAs necessary for death pronouncement practice, which resident physicians need to acquire by the end of their residency training (postgraduate year 2). METHODS: An anonymous modified Delphi study was conducted with a panel of 31 experts. The experts were invited online from general wards in hospitals with resident physicians across Japan to participate in the study using the purposive and snowball sampling method. A non-anonymous web conference was held with three additional external evaluators to finalize the item list. The consensus criterion was defined as a mean response of at least 4 points on a 5-point Likert scale for each competency and EPA item and a rating of 4 or 5 points by at least 80% of the participants. RESULTS: Consensus was achieved, with consistently high levels of agreement across panel members, on 11 competencies and 9 EPA items. Additionally, a correspondence matrix table between competencies and EPAs was developed. CONCLUSIONS: This study clarified the standardized educational outcomes as competencies in death pronouncement practice and the unit of professional practice of physicians who can perform this independently (EPAs), serving as a blueprint to aid the development of an educational model and evaluation method for clinical educational institutions and developers of medical school curriculums.

"Guidebook on Doctors' Behaviors for Death Diagnosis Created by Community Healthcare Providers" Changed Residents' Mind for Death Diagnosis.

BACKGROUND: Education regarding death diagnosis is not often included in the medical education. OBJECTIVE: To investigate the change minds at the time of death diagnosis among residents after lectures based on our guidebook. DESIGN: Uncontrolled, open-label, multi-center trial. SUBJECTS: A total of 131 doctors undergoing their initial training were enrolled this study. MEASUREMENTS: Questionnaires were administered to volunteers before and after the lecture by the clinical training instructor presented information regarding doctors' behaviors at the death diagnosis based on our guidebook at each hospital. RESULTS: The subjects had an average age of 27.1 years and comprised 76 men (58.0%) and 54 women (41.2%). A total of 83 subjects (63.4%) had learned how to diagnose death as medical students, and 52 subjects (39.7%) had experienced death diagnosis scenes as medical students. Among those who had difficulties related to death diagnoses, the highest number (88.4%) indicated that "I do not know what to say to the family after a death diagnosis". Self-evaluation significantly increased after the lecture for many items concerning explanations to and considerations of the family: the effect size for "Give words of comfort and encouragement to family" increased significantly after the lecture to 0.9. CONCLUSIONS: Few of the residents felt that they had received education regarding death diagnoses; they reported difficulties with diagnosing death and responding to patients' families. After the lecture using our guidebook, residents' mind changed significantly for death diagnosis, suggesting that the guidebook at the time of death diagnosis may be useful.

Comparison of computed tomography findings with clinical risks factors for endoscopic therapy in upper gastrointestinal bleeding cases.

Several risk scoring systems exist for acute upper gastrointestinal bleeding (UGIB). The clinical Rockall score (clinical RS) and the Glasgow-Blatchford score (GBS) are major risk scores that consider only clinical data. Computed tomography (CT) findings are equivocal in non-variceal UGIB. We compared CT findings with clinical data to predict mortality, rebleeding and need for endoscopic therapy in non-variceal UGIB patients. This retrospective, single-center study included 386 patients admitted to our emergency department with diagnosis of non-variceal UGIB by urgent endoscopy between January 2009 and March 2015. Multivariable logistic regression analysis was used to investigate CT findings and risk factors derived from clinical data. CT findings could not significantly predict mortality and rebleeding in non-variceal UGIB patients. However, upper gastrointestinal hemorrhage in CT findings better predicted the need for endoscopic therapy than clinical data. The adjusted odds ratios were 10.10 (95% CI 5.01-20.40) for clinical RS and 10.70 (95% CI 5.08-22.70) for the GBS. UGI hemorrhage in CT findings could predict the need for endoscopic therapy in non-variceal UGIB patients in our emergency department. CT findings as well as risk score systems may be useful for predicting the need for endoscopic therapy.

[Differences in Concepts between Hospital Oncologists and Home Physicians].

Although many patients with terminal cancers desire to be cared for at home, frequently, such patients cannot be shifted to home care due to their unstable symptoms. In severe cases, emergency hospitalizations may be frequently required after introducinghome medical care. We report a case of makinghome medical care difficult due to repeated emergency hospitalizations despite of the patient's deep desire. Interviews were conducted with both the oncologist in charge of the case and a home physician, and their viewpoints were compared. For patients and their families to achieve desired livingconditions, it was considered necessary to give supportive medical care that meet their desires until the end of their lives as mutual viewpoints are taken in a good balance.

[Case of Hyperammonemia Induced by High-Dose Fluorouracil].

A case of hyperammonemia induced by chemotherapy, including high-dose fluorouracil(5-FU), for advanced unresectable large intestinal cancer has been reported. This case involved an 81-year-old female who was diagnosed with pT4bcN2M1 (multiple hepatic metastases; stage Ⅳ; KRAS: mutant)after emergency surgery for sigmoid colon cancer and diffuse peritonitis. Post-operation, the 4 courses of mFOLFOX6 plus Bmab therapy was started for advanced unresectable recurrent large intestinal cancer; 48 hours later, she developed consciousness disorder(JCS Ⅲ-300). The disorder promptly disappeared after discontinuation of high-dose 5-FU. Because high-dose 5-FU was inferred to be the main cause of hyperammonemia, XELOX plus Bmab therapy was started as a post-treatment. She did not develop hyperammonemia; therefore, 8 courses were administered. The patient is being followed-up now.

[A Case of Malignant Ameloblastoma Associated with Uncontrollable Hypercalcemia].

Approximately 20-30% of cancers are associated with hypercalcemia, and this is a complication often encountered in cancer care. Hypercalcemia causes disorders such as disturbance of consciousness and, in severe cases, kidney failure and even death. In this report, we present a case of malignant ameloblastoma associated with uncontrollable hypercalcemia followed by a life-threatening disease course. In this case, hypercalcemia shortened the period of home care, and the medical staff could have extended this period by acquiring knowledge that leads to early detection and better control of hypercalcemia. In addition, the choice of the place for end-of-life care may have been expanded by considering the treatment of not only the malignant tumor but also hypercalcemia as its complication.

[Are the Medical Staff Ready to Respond to the Suffering from Sexuality of Terminal Cancer Patients ?]

The goal of palliative care is to support the ideal life of cancer patients and their partners, but the medical staff does not listen to all the needs of cancer patients and their partners. Cancer patients choose opponents and situations and express their suffering. Additionally, the typical problem of hidden suffering is not the issues of sexuality ? The suffering from sexuality of cancer patients is not expected to be expressed unless there is a suitable opponent. Are we the medical staff ready to respond to the suffering from sexuality of terminal cancer patients ? In this study, we thought that it was necessary to investigate the preparation of medical staff for the suffering from sexuality of terminal cancer patients, through a relationship with the hospitalized inpatient who reported suffering from sexuality.

[Retrospective Observational Study on Chemical Coping].

Chemical coping also has an idea that it is an early stage of abuse and dependence of opioids, it is important to grasp the frequency, complaints, and risk factors of chemical coping. In this study, observational research was performed backwardly with 549 people using opioids who were newly requested to the palliative care team. Results revealed that 13 of 549 patients (2.4%)were diagnosed with chemical coping. In terms of a breakdown of the complaint, and it was following rate and reasons, 6 people(46%)felt easy, 2 people(15%)were anxious, 2 people(15%)could sleep, 2 people(15%)had unknown reasons, and 1(8%)was calm. Characteristics of each patient diagnosed with chemical coping included frequent psychiatric symptoms such as life expectancy of 3 months, opioid oral administration period of 1 year or more, disease incidence period of 1 year or more, anxiety, delirium, and depression. One benign disease also confirmed the transition to opioid dependence.

[Practical Utilization of Home Care Support System and Influence of Home Care on the Regional Core Hospital].

The home care support system, newly established in 2014, is a system that always secures the hospitalization of pre-registered home care patients who need to be hospitalized. Ashigarakami Hospital has operated this system since April 2014. As of May 2018, a total of 215 people registered, and 156 people have died. Among the deceased patients, 77(49.4%)died at home, which was higher than the proportion of home deaths(13.0%)in the Japanese population dynamics survey in 2016. In patients who had malignant diseases, they could spend more than half of the period from their introduction to the system up to death being treated at home. Even in the case of death at a hospital, the duration of the last hospitalization was 18 days on average(median of 12 days). In most cases, patients were treated at home until shortly before death.

Comparison of the early effects of vonoprazan, lansoprazole and famotidine on intragastric pH: a three-way crossover study.

To promote symptom relief from acid-related diseases, a medicine with a rapid-onset effect is ideal. The aim of this study was to investigate the early inhibitory effect on gastric acid secretion after a single oral administration of vonoprazan, which represents a new class of proton pump inhibitors, and to compare this effect with those of lansoprazole and famotidine. Ten Helicobacter pylori (HP)-negative male subjects participated in this randomized, three-way crossover study. A single oral administration of vonoprazan (20 mg), lansoprazole (30 mg) or famotidine (20 mg) was performed, and the intragastric pH was continuously monitored for 6 h. Each drug was administered at least seven days apart. The average intragastric pH during the 6-h period after the administration of famotidine was higher than that after the administration of lansoprazole (median: 4.45 vs 2.65; p = 0.0284). A similar result was observed for vonoprazan and lansoprazole (median: 4.30 vs 2.65; p = 0.0322). In conclusions, oral administration of vonoprazan and famotidine in HP-negative healthy male subjects caused the intragastric pH to rise more quickly than did lansoprazole. (Trial Registration: UMIN000020989).

Assessment of colonic contents in patients with chronic constipation using MRI.

Although chronic constipation is common, colonic functional evaluating tests are uncommon. This study examines whether chronic constipation and gastrointestinal symptoms are correlated with the lateral diameter of the colon measured from MRI images. We included chronic constipation patients in a prospective, cross-sectional study using MRI at three centers. We divided 3D MRI colorectal images into 6 segments using with specified sequences and selected the maximum luminal diameter from each segment. We used the GSRS questionnaire to evaluate gastrointestinal symptoms. We evaluated the correlation between luminal diameters and GSRS scores. We found the following positive correlations: descending colon and unsatisfactory defecation symptoms; sigmoid colon and diarrhea; and rectum and constipation. The sum and ratio of the ascending and sigmoid colon diameters correlated with nausea and diarrhea. The sum of the transvers to the sigmoid colon diameter also correlated with nausea and diarrhea. The sum of all segment diameters correlated with nausea and constipation. In conclusion, we showed cross-sectional study of colonic MRI correlate with gastrointestinal symptoms. MRI might be useful for colonic motility evaluations to determine appropriate constipation treatments (Clinical trial registry number UMIN 000021274).

[Combination Therapy of Oxycodone and Tapentadol Was Effective for Intractable Pain Caused by Breast Cancer Bone Metastasis - A Case Report].

A 52-year-old woman had been prescribed oral medication of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and oxycodone for intractable pain associated with thoracic metastasis of breast cancer. However, the pain control was poor. Although pregabalin and gabapentin were used as supplementary analgesics, they could not be continued because of their side effects. Based on the noradrenalin reincorporation-inhibiting action of tapentadol, a combination therapy of tapentadol and oxycodone was introduced and satisfactory pain control was achieved. No side effects from the combined opioids were observed. This finding indicates the potential of administrating a combination therapy of m-opioid receptor agonists(such as morphine, oxycodone, and fentanyl)with tapentadol, which has a noradrenaline reincorporation-inhibiting action, as an effective remedy for alleviating intractable pain complicated with neuropathic pain.

[Fentanyl Citrate Sublingual Tablets Were Effective in Relieving Symptoms of Akathisia - A Case Report].

Akathisia is a condition wherein sitting calmly and quietly is impossible, with a representative complaint of restless legs. It is generally assumed to be caused by anti-dopamine activity. In severe cases, it has been known to result in suicide attempt. We reported a case of drug-induced akathisia with difficulty in oral intake, in which fentanyl citrate sublingual tablets were found to be effective in relieving symptoms. The patient was a female aged 50's who had a gastric cancer with peritoneal dissemination causing pain and vomiting. Palliative care was requested for management of symptoms. Metoclopramide and haloperidol were administered for vomiting. However, because of the complaints of restless legs, the case was diagnosed as drug-induced akathisia. Fentanyl citrate sublingual tablets were then administered for pain management, resulting in temporary improvement of akathisia symptoms.

[Usefulness of Suvorexant for Complicated Delirium in Cancer Patients Who Experience Sleep Disturbance during Hospitalization].

We investigated the usefulness of suvorexant for complicated delirium in patients with cancer who experience sleep disturbance during hospitalization. Nine patients with malignant tumors complicated with symptoms of delirium and insomnia were included in this study; their palliative care was managed by the palliative care team of our hospital for a period of one year from April 2016 to March 2017. A retrospective follow-up study was then conducted. The Japanese version of DRS-R98 was used to evaluate the severity of the patient's delirium. The total severity score of DRS-R98 significantly decreased after the administration of suvorexant when compared to the score before its administration(6.66±1.73 vs 10±3.20, p=0.0031). In addition, suvorexant did not exhibit any harmful effects. Our results indicate that suvorexant was useful in alleviating delirium symptoms in cancer patients who experience sleep disturbance.

[Assessing Patient Factors Influencing the Discontinuation of Opioids after Intra-Arterial Chemotherapy for Oral Cancer - A Retrospective Study].

Superselective intra-arterial chemoradiation therapy for oral cancer induces the complication of mucositis. Although the associated pain is controlled using opioids, major questions from patients in clinical practice are as follows:(1)the mean number of days from the completion of superselective intra-arterial chemoradiation therapy to the discontinuation of opioid administration, and(2)patient factors enabling the discontinuation of opioids. The purpose of this study was to clarify these points. A retrospective follow-up study was conducted from April 2016 to March 2017 on patients who underwent superselective intra-arterial chemoradiation therapy at our department of oral surgery. The patients were divided into 2 groups:one who discontinued opioids, and the other who did not. Clinical backgrounds and data were compared between the 2 groups. The mean number of days from the completion of superselective intra-arterial chemoradiation therapy to the discontinuation of opioid administration was 51±34.4 days. The absence of diabetes and deliria during treatment were determined as factors contributing to the discontinuation of opioids.

[Patient Factors Enabling the Decannulation of the Gastrostomy Tube after Superselective Intra-Arterial Chemoradiation Therapy for Locally Advanced Oral Cancer - A Retrospective Study].

Superselective intra-arterial chemoradiation therapy for locally advanced oral cancer induces complications such as mucositis, which impedes oral intake. Thus, at our hospital, a gastrostomy is performed in almost all patients during the treatment period to ensure the presence of an alternative administration route for nutrition and drugs. The purpose of this study was to calculate the mean number of days from completion of superselective intra-arterial chemoradiation therapy to the decannulation of gastrostomy, and extract patient factors for the decannulation. A retrospective follow-up study was conducted from April 2016 to March 2017 on patients who underwent superselective intra-arterial chemoradiation therapy at our department of oral surgery. The patients were divided into 2 groups:one who was decannulated and the other who did not. Clinical backgrounds and data were compared between the 2 groups. In the group with the decannulation, the mean period from treatment completion to the decannulation was 132±51.6 days. Heavy alcohol consumption, absence of haphalgesia before treatment, and possible securement of the opening with the breadth of 3 fingers, were determined as factors contributing to the decannulation of gastrostomy tube.

Can sedation using a combination of propofol and dexmedetomidine enhance the satisfaction of the endoscopist in endoscopic submucosal dissection?

BACKGROUND AND STUDY AIMS: The aim of this pilot randomized controlled trial was to evaluate and compare the satisfaction of the endoscopist along with the effectiveness and safety of sedation between sedation protocol using a combination of propofol (PF) and dexmedetomidine (DEX) (Combination group) and sedation protocol using PF alone (PF group) during gastric endoscopic submucosal dissection (ESD). PATIENTS AND METHODS: Fifty-eight patients with gastric neoplasias scheduled for gastric ESD were enrolled and randomly assigned to the two groups. The satisfaction scores of the endoscopists and the parameters for the effectiveness and safety of sedation were evaluated by comparisons between the two groups. RESULTS: The satisfaction scores of the endoscopists, which were measured using a visual analogue scale, were significantly higher in the Combination group than in the PF group (88 vs. 69, P  = 0.003). The maintenance dose of PF was lower in the Combination group than in the PF group (2 mg/kg/h vs. 5 mg/kg/h, P  < 0.001), and the number of rescue PF injections was fewer in the Combination group than in the PF group (2 times vs. 6 times, P  < 0.001). The incidence of bradycardia (defined as a pulse rate ≤ 45 bpm) in the Combination group was higher than that in the PF group (37.9 % vs. 10.3 %, P  = 0.029). CONCLUSIONS: This study suggests that gastroenterologist-directed sedation using a combination of PF and DEX during gastric ESD can enhance the satisfaction levels of endoscopists by providing stable sedation with an acceptable safety profile.

Lubiprostone improves visualization of small bowel for capsule endoscopy: a double-blind, placebo-controlled 2-way crossover study.

BACKGROUND AND STUDY AIMS: Lubiprostone has been reported to be an anti-constipation drug. The aim of the study was to investigate the usefulness of lubiprostone both for bowel preparation and as a propulsive agent in small bowel endoscopy. PATIENTS AND METHODS: This was a double-blind, placebo-controlled, 2-way crossover study of subjects who volunteered to undergo capsule endoscopy (CE). A total of 20 subjects (16 male and 4 female volunteers) were randomly assigned to receive a 24-µg tablet of lubiprostone 120 minutes prior to capsule ingestion for CE (L regimen), or a placebo tablet 120 minutes prior to capsule ingestion for CE (P regimen). Main outcome was gastric transit time (GTT) and small-bowel transit time (SBTT). Secondary outcome was adequacy of small-bowel cleansing and the fluid score in the small bowel. The quality of the capsule endoscopic images and fluid in the small bowel were assessed on 5-point scale. RESULTS: The capsule passed into the small bowel in all cases. Median GTT was 57.3 (3 - 221) minutes for the P regimen and 61.3 (10 - 218) minutes for the L regimen ( P  = 0.836). Median SBTT was 245.0 (164 - 353) minutes for the P regimen and 228.05 (116 - 502) minutes for the L regimen ( P  = 0.501). The image quality score in the small bowel was 3.05 ±â€Š1.08 for the P regimen and 3.80 ±â€Š0.49 for the L regimen ( P  < 0.001). The fluid score in the small bowel was 2.04 ±â€Š1.58 for the P regimen and 2.72 ±â€Š1.43 for the L regimen ( P  < 0.001). There was a significant difference between the 2 regimens with regard to image quality. The fluid score was more plentiful for the L regimen than for the P regimen. There were no cases of capsule retention or serious adverse events in this study. CONCLUSION: Our study showed that use of lubiprostone prior to CE significantly improved visualization of the small bowel during CE as a result of inducing fluid secretion into the small bowel.