Family satisfaction with inpatient palliative care in Japan.

Whereas satisfaction is one of the most important outcomes in palliative care settings, there have been no systematic studies investigating the effects of family- and organization-related variables on family satisfaction with care. To clarify factors contributing to family satisfaction with inpatient palliative care services, a cross-sectional mailed survey was performed. A 60-item questionnaire was mailed to 1026 bereaved subjects who had lost family members at one of 37 palliative care units in Japan to evaluate their sociodemographic characteristics and satisfaction levels with care. An institution survey was performed to collect organization-related variables. Caregiver satisfaction was rated on the Satisfaction scale for Family members receiving Inpatient Palliative Care (Sat-Fam-IPC). A total of 640 responses were analysed (response rate = 62%). The responses to overall satisfaction were 'satisfied' in 41 % and 'very satisfied' in 47%. The mean total score of the Sat-Fam-IPC was 82.4 +/- 13.2 on the 0-100 scale. The mean subscale scores were: 85.8 +/- 14.5 (Nursing Care), 81.5 +/- 18.4 (Symptom Palliation), 85.0 +/- 13.8 (Facility), 83.3 +/- 16.6 (Information), 83.1 +/- 17.3 (Availability), 78.3 +/- 18.9 (Family Care), and 79.8 +/- 17.3 (Cost). Significant determinants of family satisfaction identified were: nursing system, the number of nurses at night and presence of attending medical social workers (Nursing Care), patient age and the number of physicians (Symptom Palliation), floor space per bed (Facility), duration of admission and presence of attending medical social workers (Availability), patient age, family age, gender and occupational status (Family Care), patient age and the extra charge for a private room (Cost). In conclusion, informal caregivers are generally satisfied with inpatient palliative care services provided by members of the Japanese Association of Hospice and Palliative Care Units. The levels of satisfaction are influenced by various family- and organization-related variables.

A scale to measure satisfaction of bereaved family receiving inpatient palliative care.

Although satisfaction is an important outcome of medical care, there are no validated tools to quantify family satisfaction with hospital-based palliative care. In this nationwide postal survey, an instrument to measure informal carer satisfaction with an inpatient palliative care service was validated. A 60-item questionnaire was mailed to 1344 bereaved people who had lost their family members at 50 palliative care units in Japan, and 850 responses were analysed (response rate = 64%). The reliability, construct validity, and convergent validity of the scale were examined after the responses were randomly divided into two groups: a training set used in the development phase (n = 500) and a testing set used in the validation phase (n = 350). The number of scale items was reduced from 50 to 34 through psychometric techniques in the development phase. In the testing sample, the overall Cronbach's coefficient alpha for the final 34-item scale was 0.98. A factor analysis revealed that the scale consisted of seven subcategories: Nursing Care, Facility, Information, Availability, Family Care, Cost, and Symptom Palliation. The total score of the scale was significantly correlated with the degree of global satisfaction of the bereaved (Spearman's rho = 0.78). In conclusion, this 34-item scale, the Satisfaction Scale for Family Members Receiving Inpatient Palliative Care (Sat-Fam-IPC), has acceptable psychometric properties and would be a useful tool to measure carer satisfaction with an inpatient palliative care service.

Underlying pathologies and their associations with clinical features in terminal delirium of cancer patients.

Delirium is a common complication in terminally ill cancer patients. Identification of underlying pathologies and prediction of clinical features may improve effective symptom alleviation. This study aims to clarify precipitating factors and their associations with clinical features of terminal delirium. Consecutive hospice inpatients who developed delirium were prospectively evaluated following a structured protocol. Among 237 patients followed until death, 245 episodes of delirium were identified in 213 patients. Precipitating factors for delirium were disclosed in 93% of the 153 cases in which investigations were completed. Mean number of etiologies was 1.8 +/- 1.1 per patient, and two or more factors were recognized in 52%. The main pathologies identified were hepatic failure, medications, prerenal azotemia, hyperosmolality, hypoxia, disseminated intravascular coagulation, organic damage to the central nervous system, infection, and hypercalcemia. Occurrence of hyperactive delirium and the requirement for symptomatic sedation significantly correlated with hepatic failure, opioids, and steroids, while dehydration-related pathologies were significantly associated with hypoactive delirium. Complete recovery was frequently achieved in cases with medication- and hypercalcemia-induced delirium, whereas a low remission rate was related to hepatic failure, dehydration, hypoxia, and disseminated intravascular coagulation. In conclusion, standard examinations can confirm factors potentially contributing to delirium and thereby predict the severity of agitation and clinical outcomes.

Influence of renal function on serum and urinary heart fatty acid-binding protein levels.

BACKGROUND: Serum heart fatty acid-binding protein (H-FABP) has been reported to be a sensitive and early indicator of myocardial damage. However, circulating H-FABP may be cleared considerably from kidney, similar to that found for myoglobin. Therefore, the possibility exists that any change in renal function affects serum H-FABP concentration, and thus leads to erroneous interpretation. To evaluate the influence of renal function on H-FABP levels, we conducted a prospective study. METHODS: Nineteen patients undergoing isolated primary coronary artery bypass grafting were enrolled in this study. The patients were classified by the preoperative creatinine clearance into two groups: the control group (n=12); patients with creatinine clearance of 40 mL/min or greater, and the renal dysfunction group (n=7); patients with creatinine clearance of less than 40 mL/min. Serum H-FABP, CK-MB, troponin-T and urinary H-FABP levels were measured perioperatively. RESULTS: None of the patients had perioperative myocardial infarction. No significant differences were found in CK-MB and troponin-T levels between the groups. The renal dysfunction group resulted in significantly (p<0.05) higher serum H-FABP levels and lower urinary H-FABP levels than those in the control group, postoperatively. The creatinine clearance correlated inversely with the peak levels of serum H-FABP (r=-0.75, p=0.0001) and correlated with the peak levels of urinary H-FABP (r=0.64, p=0.003). CONCLUSIONS: The results indicate that the kidneys play an important role in the clearance of serum H-FABP. Thus, caution must be taken in interpreting this marker for myocardial damage during cardiac surgery in patients with renal dysfunction.

Improved accuracy of physicians' survival prediction for terminally ill cancer patients using the Palliative Prognostic Index.

The Palliative Prognostic Index (PPI) has recently been developed for survival prediction in terminally ill cancer patients. To clarify whether physicians' clinical prediction of survival (CPS) can be improved using this objective assessment aid, two sequential prospective studies were performed on two independent series of hospice inpatients (n = 150 and 108). In the first study, the CPS was prospectively recorded by primary physicians on the basis of their clinical experiences. In the second study, physicians estimated patient prognoses with a reference to the PPI score. The cases where the differences between actual survival (AS) and CPS were 28 days or longer significantly decreased in the second study compared to the first study (42% vs 23%, P < 0.01). Also, the cases where AS was either twice longer or half shorter than CPS significantly declined (49% vs 37%, P = 0.050). As well, serious errors, defined as the cases where AS was either (a) 28 days and twice longer than CPS or (b) 28 days and half shorter than CPS, significantly decreased from 27% in the first study to 16% in the second study (P = 0.028). In conclusion, the PPI can contribute to improvement in physicians' ability to predict survival of terminally ill cancer patients.

Determinants of the sensation of thirst in terminally ill cancer patients.

While a sensation of thirst causes severe distress for a certain proportion of cancer patients in the terminal stage, the factors contributing to this symptom have not been established. To clarify the association between sensation of thirst and medical factors, especially dehydration, a cross-sectional observational study was performed on terminally ill cancer patients receiving inpatient hospice care. On admission to a palliative care unit, 88 consecutive patients underwent blood sampling and were requested to rate the intensity of thirst on a visual analogue scale (VAS). Physicians prospectively evaluated factors that might potentially be contributing to the symptom. The mean VAS score for thirst was 5.0+/-2.8, and 18% of the patients complained of severe thirst with a VAS score of > or = 8. No significant correlations were observed between the VAS score for thirst and the values of total protein, blood urea nitrogen (BUN), creatinine, sodium, osmolality, hematocrit, atrial natriuretic peptide (ANP), and biochemical dehydration defined by the levels of BUN, creatinine, sodium and osmolality. On the other hand, dehydration defined by ANP level (< or = 15 pg/ml), hyperosmolality (> or = 300 mosmol/kg), gastrointestinal cancer, survival, performance status, oral intake, vomiting, and stomatitis were significantly associated with the severity of thirst. In addition, mouth breathing and opioids were determined to be a potential clinical cause of severe thirst when a retrospective chart review was carried out. In conclusion, sensation of thirst is a frequent symptom in terminally ill cancer patients and is associated with dehydration, hyperosmolality, poor general conditions, stomatitis, oral breathing, and opioids. Careful assessments and treatment of underlying causes is important to alleviate patients' distress.

Communication Capacity Scale and Agitation Distress Scale to measure the severity of delirium in terminally ill cancer patients: a validation study.

Although valid measurement of the severity of terminal delirium is of great importance in palliative care settings, existing instruments have considerable limitations. In order to quantify patients' communication capacity and agitated behaviour, two new operational observer-rating scales, the Communication Capacity Scale (Communication Scale) and Agitation Distress Scale (Agitation Scale), were validated. Thirty terminally ill cancer patients diagnosed with delirium were evaluated simultaneously by two palliative care physicians blinded to each other's coding using the Communication Scale and Agitation Scale. In addition, the Memorial Delirium Assessment Scale (MDAS), Delirium Rating Scale (DRS) and Sedation Scale were rated by one researcher. Both scales achieved high internal consistency and inter-rater reliability with Cronbach's alpha coefficients of 0.91 and 0.96, and Cohen's kappa values on each item of 0.72-1.00. The principal components analysis resulted in the emergence of only one component for each scale. The total score on the Communication Scale was highly associated with that of the MDAS (rho = 0.78), Sedation Scale (rho = 0.86), and cognitive items from the MDAS and DRS (rho = 0.83). The whole score on the Agitation Scale was significantly correlated with that of the DRS (rho = 0.61) and agitation items from the MDAS and DRS (rho = 0.61). In conclusion, the Communication Scale and Agitation Scale have acceptable reliability and validity to quantify patients' communication capacity and agitation symptoms of terminally ill cancer patients with delirium.

Antiinflammatory effects of colforsin daropate hydrochloride, a novel water-soluble forskolin derivative.

BACKGROUND: To evaluate the effects of colforsin daropate hydrochloride (colforsin), a water-soluble forskolin derivative, on hemodynamics and systemic inflammatory response after cardiopulmonary bypass, we conducted a prospective randomized study. METHODS: Twenty-nine patients undergoing coronary artery bypass grafting were randomized to receive either colforsin treatment (colforsin; n = 14) or no colforsin treatment (control; n = 15). Administration of colforsin (0.5 microg.kg(-1).min(-1)) was started after induction of anesthesia and was continued for 6 hours. Perioperative cytokine and cyclic adenosine monophosphate levels, hemodynamics, and respiratory function were measured serially. RESULTS: Marked positive inotropic and vasodilatory effects were observed in patients receiving colforsin. Interleukin 1beta, interleukin 6, and interleukin 8 levels after cardiopulmonary bypass were significantly (p < 0.05) lower in the colforsin group. Plasma levels of cyclic adenosine monophosphate increased significantly (p < 0.05) in the colforsin group, and the levels correlated inversely (r = -0.56, p = 0.002) with the respiratory index after cardiopulmonary bypass. CONCLUSIONS: Intraoperative administration of colforsin daropate hydrochloride had potent inotropic and vasodilatory activity and attenuated cytokine production and respiratory dysfunction after cardiopulmonary bypass. The results indicate that the technique can be a novel therapeutic strategy for the systemic inflammatory response associated with cardiopulmonary bypass.

[Effects of colforsin daropate hydrochloride in patients undergoing coronary artery bypass surgery].

The effects of Adehl, colforsin daropate hydrochloride, on hemodynamics were studied in patients undergoing cardiac surgery. Twenty-six patients who underwent coronary artery bypass grafting were divided into two groups according to the intraoperative administration of Adehl. The control group (n = 14) received no Adehl treatment and the Adehl group (n = 12) received Adehl infusion immediately after anesthesia induction (0.5 microgram.kg-1.min-1) for 6 hours. Hemodynamic measurements and clinical results were accessed perioperatively. The Adehl group resulted in significantly (p < 0.05) lower pulmonary capillary wedge pressure and systemic vascular resistance, and significantly (p < 0.05) greater cardiac indices and left ventricular stroke work indices than those in the control group. No significant difference was found in the rate pressure product between the groups. The Adehl group resulted in significantly shorter duration of intubation and ICU stay. Adehl was not associated with a significant increase in the prevalence of adverse effects. The results suggest that Adehl has positive inotropic and vasodilator effects without increasing myocardial oxygen consumption. Thus, it is suggested that Adehl can be a useful agent for the perioperative management in patients undergoing cardiac surgery.

Effects of high dose opioids and sedatives on survival in terminally ill cancer patients.

Concerns that high dose opioids and sedatives might shorten patient survival could contribute to insufficient symptom alleviation for terminally ill cancer patients. To examine the effects of opioids and sedatives prescribed in the final 48 hours on patient survival, a re-analysis of the prospectively collected data was performed on 209 hospice inpatients. Patient characteristics and clinical symptoms were prospectively recorded, and information about the use of opioids and sedatives in the last two days was collected by a chart review. Opioids were prescribed in 82% of the patients, with a median dose of 80 mg oral morphine equivalent (OME)/48 hours. Sixty percent received some sedative medications, mainly haloperidol (43% of total sample, 7.5 mg/48 hours), midazolam (23%, 23mg/48 hours), and hydroxyzine (15%, 50 mg/48 hours). There were no significant differences in survival between the patients who received different doses of opioids (<240, 240--599, and > or =600 mg OME/48 hours) and of benzodiazepines (0, 1--59, and > or =60 mg parental midazolam equivalent/48 hours). Also, the survival of patients with haloperidol, hydroxyzine, and other sedative medications did not differ from those without. Furthermore, an addition of use of opioids and sedatives in the final 48 hours into the multiple regression model for survival prediction achieved no significant increase in predictability. In conclusion, opioids and sedatives used for symptom control in the last days are not associated with patient survival. They are safe and useful medications to palliate severe distress in the terminal stage of cancer when administered with a low initial dosage and adequate titration.

Coronary artery bypass grafting in patients with mild renal insufficiency.

UNLABELLED: It is well known that dialysis-dependent renal failure increases the likelihood of a poor outcome following cardiac surgery. However, it is not known whether non-dialysis-dependent mild renal insufficiency also influences clinical outcome. Fifty-five patients with non-dialysis-dependent renal insufficiency undergoing coronary artery bypass grafting (CABG) (Renal group: serum creatinine level >1.5 mg/dl) were enrolled. These patients were then matched on prognostic variables to 148 patients with normal renal function ( CONTROL GROUP: serum creatinine level <1.5 mg/dl). The early postoperative clinical results showed that patients in the Renal group were more likely to develop postoperative renal failure (18% vs 1%: p=0.0002) and hemorrhage requiring re-exploration (11% vs 2%; p=0.01). Total morbidity was significantly higher in the Renal group (40% vs 22%; p=0.01). Multivariate analysis revealed that the Renal group was the second most important predictor of morbidity (odds ratio (OR) =2.2) behind left ventricular dysfunction (OR=2.9). The Renal group was also the second most important predictor of postoperative renal failure (OR=12.5). Therefore, non-dialysis-dependent mild renal insufficiency also increases the risk of morbidity following CABG.

Aortic dissections complicating open cardiac surgery: report of three cases.

Between June 1991 and February 1999, three patients suffered ascending aortic dissection as a complication of cardiopulmonary bypass operations with aortic cannulation at our hospital. The dissection occurred during the operation in two of the three patients and several months after the operation in one. Among a total of 2207 cardiac operations performed during this period, the incidence of perioperative ascending aortic dissection was 0.14%. In addition to visual inspection and palpation, either epicardial or transesophageal echocardiography proved extremely useful for establishing an intraoperative diagnosis of ascending aortic dissection as a complication of open cardiac operation. One of the three patients underwent closed plication but subsequently died of vital organ ischemia. In this case, failure of reapproximation of the injured intima by closed plication might have led to extension of the dissection. Despite prolonged cardiopulmonary bypass and myocardial ischemic time, graft replacement of the ascending aorta was successfully carried out in the other two patients. Thus, we believe that graft replacement of the ascending aorta should be performed for patients with extensive aortic dissection complicating an open cardiac operation.

Biological activity of endogenous atrial natriuretic peptide during cardiopulmonary bypass.

To evaluate the effect of cardiopulmonary bypass (CPB) on atrial natriuretic peptide (ANP) biological activity in patients undergoing cardiac operations, we conducted a prospective study. Ten patients undergoing mitral valve surgery were enrolled. Plasma levels of ANP and cyclic guanosine monophosphate (cGMP), hemodynamic variables, and renal function parameters were assessed perioperatively. The molar ratio of cGMP to ANP (as a marker for ANP biological activity) decreased significantly (p < 0.05) during CPB despite similar plasma ANP levels. The ratio correlated inversely with the duration of CPB (r = -0.85, p = 0.002). The ratio also correlated with fractional sodium excretion (r = 0.65, p = 0.04) and correlated inversely with pulmonary vascular resistance (r = -0.79, p = 0.009) and atrial filling pressure (r = -0.84, p= 0.003) postoperatively. CPB decreased the molar ratio of cGMP to ANP, which may represent ANP biological activity, such as vasodilation and natriuresis. The phenomenon may contribute to water-sodium retention and pulmonary hypertension after cardiac surgery.

Effects of intraoperative administration of atrial natriuretic peptide.

BACKGROUND: Biological activity of endogenous atrial natriuretic peptide (ANP) may decrease during cardiopulmonary bypass. To evaluate the effects of intraoperative administration of exogenous ANP in patients undergoing cardiopulmonary bypass, we conducted a prospective randomized study. METHODS: Eighteen patients undergoing mitral valve surgery were randomized to receive either ANP treatment (ANP group; n = 9) or no ANP treatment (control group; n = 9). Atrial natriuretic peptide was given immediately after initiation of cardiopulmonary bypass for 6 hours (0.05 microg x kg(-1) x min(-1)). Plasma ANP, brain natriuretic peptide and cyclic guanosine monophosphate (cGMP) levels, hemodynamic variables and renal function were assessed perioperatively. RESULTS: Administration of ANP increased plasma cyclic guanosine monophosphate levels, urine output and fractional sodium excretion, and decreased preload, afterload and plasma brain natriuretic peptide levels significantly (p < 0.05). Plasma cyclic guanosine monophosphate levels correlated with plasma ANP levels (r = 0.95, p = 0.0001), correlated with fractional sodium excretion (r = 0.53, p = 0.02), and correlated inversely with systemic vascular resistance (r = -0.54, p = 0.02). CONCLUSIONS: Intraoperative administration of ANP had potent effects on natriuresis and systemic vasodilation by elevating cyclic guanosine monophosphate levels. The results suggest that the technique is useful for the management of hemodynamics and water-sodium retention after cardiopulmonary bypass.

Effects of angiotensin-converting enzyme inhibitor during warm blood cardioplegia.

BACKGROUND: Effects of captopril, an angiotensin-converting enzyme inhibitor, during warm blood cardioplegia were assessed in the blood-perfused, isolated rat heart. METHODS: The isolated hearts were arrested for 60 minutes with warm blood cardioplegia given at 20-minute intervals and were reperfused for 60 minutes. The control group (n = 10) received standard cardioplegia and the captopril group (n = 10) received cardioplegia supplemented with captopril (2 mmol/L). Cardiac function, myocardial metabolism, and cardiac release of circulating adhesion molecules were assessed before and after cardioplegic arrest. RESULTS: Left ventricular end-diastolic pressure and -dp/dt were significantly (p<0.05) lower and coronary blood flow was significantly (p<0.05) greater in the captopril group than the control group during reperfusion. The captopril group resulted in significantly (p<0.05) less cardiac release of lactate, thiobarbituric acid reactive substances during reperfusion. Cardiac release of intercellular adhesion molecule-1 was significantly (p<0.05) less in the captopril group at 60 minutes of reperfusion. CONCLUSIONS: The results suggest that supplementation of captopril during warm blood cardioplegia provides superior myocardial protection by suppressing lipid peroxidation and leukocyte-endothelial cell interaction during reperfusion.

Coronary artery bypass surgery in a patient with myasthenia gravis.

A 73-year-old man with myasthenia gravis required quadruple coronary artery bypass grafting due to triple-vessel disease. Anesthetic management was performed with general anesthesia using a reduced dose of muscle relaxant with the aid of a neuromuscular transmission monitor. He was extubated 14 hrs after surgery without difficulty under this monitor. His postoperative course was uneventful. A patient with myasthenia gravis who required coronary artery bypass surgery was successfully performed by the deliberate preoperative evaluation of patient's myasthenic and cardiac status, and by the careful perioperative management.

Surgical treatment for graft stenosis after repair of an interrupted aortic arch: report of two cases.

We report herein two cases of patients who underwent successful reoperation for graft stenosis after repair of an interrupted aortic arch (IAA). The first patient was a 10-year-old girl who suffered from upper limb hypertension 9 years after her initial operation. Cardiac catheterization revealed a pressure gradient of 55 mmHg across the repaired arch. At reoperation, a left subclavian turndown anastomosis was performed, following which the hypertension resolved and a cardiac catheterization done 5 years later demonstrated sufficient growth of the restored arch with no significant gradient. The second patient was a 17-year-old boy who suffered from general fatigue and intermittent hypertension 12 years after his initial operation. Cardiac catheterization revealed a gradient of 60 mmHg across the repaired arch. He underwent an extraanatomic ascending to descending aortic bypass employing an additional 18-mm graft, and a postoperative cardiac catheterization showed no gradient between the ascending and descending aorta. Our experience has shown that IAA should be repaired without prosthetic grafts if possible. Although extraanatomic bypass is useful for reducing the operative risks at reoperation, a large graft should be used to avoid the need for a third operation. For young children expected to outgrow a second graft, performing an endogenous anastomosis, such as a left subclavian turndown anastomosis, should be considered as an alternative.

A case report of surgical treatment of quadricuspid aortic valve associated with regurgitation.

A case of a 65-year-old woman who had a quadricuspid aortic valve associated with aortic regurgitation is reported. The patient had severe aortic regurgitation and four equally divided aortic cusps. The valve abnormality was detected by a transesophageal echo and an aortography. The incomplete aortic valve was excised and replaced by a St. Jude Medical prosthesis. Although this case had no coronary abnormality, a coronary displacement is often reported in quadricuspid aortic valve cases. In order to perform an operation safely, accurate information which is obtained by a non-invasive examination of the transesoph-ageal echo is quite valuable as it can indicate the need for further preoperative examinations of the coronary arteries.

Plasma exchange for hyperbilirubinemia following implantation of a left ventricle assist system: a case report.

A 49-year-old patient with end-stage dilated cardiomyopathy underwent implantation of a left ventricular assist system (LVAS). Although the systemic circulation seemed to be improved, the serum total bilirubin (Tbili) level increased sharply in the early postoperative period (preoperative Tbili, 5.7 mg/dl; postoperative day 3, 33.6 mg/dl). Plasma exchange (PE) was performed 7 times from postoperative day 4, and the Tbili level decreased to 16.3 mg/dl by postoperative day 11. Thereafter, serum Tbili normalized concomitant with improved circulatory condition. The cause of the hyperbilirubinemia was considered to be temporary right ventricular dysfunction or hepatic sinusoid endothelial dysfunction. The liver function was recoverable, so PE had been effective in this case. Unfortunately, the patient suffered a midbrain infarction and ultimately died. From this experience, PE is recommended if it is judged that liver function can be preserved and circulation is adequate, but its implementation should not be delayed. It is essential that LVAS is implanted before damage occurs to end-organ function and thus prevent hyperbilirubinemia.

[Hemodynamic assessment of the Carpentier-Edwards pericardial valve compared with the St. Jude Medical valve in the aortic position using dobutamine-stress echocardiography].

To assess the hemodynamic performance of the prosthetic valve in the aortic position, we examined dobutamine-stress echocardiography (DSE) to the patients underwent AVR with CEP valve or SJM valve. In 23 mm size, there were no significant differences between CEP group and SJM group in Peak velocity of the aortic jet (PV), peak pressure gradient (PPG) and effective orifice area (EOA). On the other hand, in 21 mm size, PV and PPG of the CEP group were significantly lower than those of the SJM group after DSE. The EOA of the CEP group was significantly larger than that of the SJM group after DSE. Our results suggest that the hemodynamic function of the CEP valve is superior to that of the SJM valve especially in small aortic annuli.