Association Among End-Of-Life Discussions, Cancer Patients' Quality of Life at End of Life, and Bereaved Families' Mental Health.

End-of-life discussions are essential for patients with advanced cancer, but there is little evidence about whether these discussions affect general ward patients and family outcomes. We investigated the status of end-of-life discussions and associated factors and their effects on patients' quality of death and their families' mental health. Participants in this retrospective cross-sectional observational study were 119 bereaved family members. Data were collected through a survey that included questions on the timing of end-of-life discussions, quality of palliative care, quality of patient death, and depression and grief felt by the families. Approximately 64% of the bereaved family members participated in end-of-life discussions between the patient and the attending physician, and 55% of these discussions took place within a month before death. End-of-life discussions were associated with the patients' prognostic perception as "incurable, though there is hope for a cure" and "patients' experience with end-of-life discussions with family before cancer." There was a small decrease in depression and grief for families of patients who had end-of-life discussions. Those who did not have end-of-life discussions reported lower quality of end-of-life care.

Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101).

BACKGROUND: Although the efficacy of parenteral morphine for alleviating dyspnea has been previously demonstrated in several studies, little is known regarding the efficacy of oral morphine for dyspnea among patients with cancer, including its response rate and predictive factors of effectiveness. Therefore, the aim of this study was to clarify the effectiveness of oral morphine on dyspnea in patients with cancer and elucidate the predictive factors of its effectiveness. SUBJECTS, MATERIALS, AND METHODS: In this multicenter prospective observational study, we investigated the change in dyspnea intensity in patients with cancer before and after the administration of oral morphine by using a visual analog scale (VAS). We also administered a self-assessment questionnaire to determine whether the patients believed oral morphine was effective. RESULTS: Eighty patients were enrolled in the study, and 71 of these patients were eligible. The least square mean of the VAS scores for dyspnea intensity was 53.5 at baseline, which decreased significantly to 44.7, 40.8, and 35.0 at 30, 60, and 120 minutes after morphine administration, respectively. Fifty-four patients (76.1%) reported that oral morphine was effective on the self-assessment questionnaire. Among the background factors, a high score for "sense of discomfort" on the Cancer Dyspnea Scale (CDS) and a smoking history of fewer pack-years were associated with greater effectiveness. CONCLUSION: Oral morphine was effective and feasible for treating cancer-related dyspnea. A higher score for "sense of discomfort" on the CDS and a smaller cumulative amount of smoking may be predictive factors of the effectiveness of oral morphine. IMPLICATIONS FOR PRACTICE: This study demonstrated that oral morphine was effective in alleviating cancer-related dyspnea due to multiple factors including primary lung lesions, airway narrowing, and pleural effusion. Approximately 76% of patients reported that oral morphine was effective. A higher score for "sense of discomfort" on the Cancer Dyspnea Scale and a lower cumulative amount of smoking may be predictive factors for the effectiveness of oral morphine. Interestingly, respiratory rates in patients who reported the morphine to be effective decreased significantly after oral morphine administration, unlike the respiratory rates in "morphine-ineffective" patients.

[Change of the patient characteristics among adult asthmatics hospitalized due to acute exacerbation].

BACKGROUND: We analysed the patient characteristics among adult asthmatics hospitalized to our hospital to clearfy the residual problems in the prevention and treatment of asthma. METHODS: We identified the adult asthmatics hospitalized to our hospital during the period A: Jan 2004-Dec 2005 and the period B: Jan 2009-Dec2010 and analysed retrospectively around age, smoking history, and the use of ICS (including combination medicine) and so on. RESULTS: The total patient numbers were A: 161 and B: 88, decreasing to almost half. The rates of the patients older than 65 years were equivalent between the 2 groups. Categorized according to age, in the group <65 years old, the rates of ICS use were A: 22.9% and B: 35.8% and the current smoking rates were A: 42.7% and B: 49.1% respectively. In the group 65≤ years old, the rates of ICS use were A: 46.2% and B: 48.6%, and the current smoking rates were A: 19.7% and B: 22.9%. CONCLUSION: In the group <65 years old, ICS has become more popular but smoking rate has increased among hospitalized adult asthmatics. It is estimated that smoking leads to reduce the effect of ICS and the strategy of smoking cessation will be needed to reduce acute exacerbations. In the group 65≤ years old, ICS is relatively more popular than youth and smoking rate is limited. Asthma among elder people may be refractory and more efficient strategies must be required.

[A case of drug-induced pneumonitis due to a cold remedy].

The patient was an 84-year-old woman who took a combination cold remedy, Shin-Rulu-A' for three days because of fever and cough. However, her symptoms worsened and she visited our hospital. Arterial blood gas analysis revealed severe hypoxemia and chest computed tomography showed diffuse ground glass opacities in both lungs. Analysis of bronchoalveolar lavage fluid disclosed an increased proportion of lymphocytes. The cold remedy was stopped, corticosteroids were administered, and she recovered. After positive results of lymphocyte stimulation testing to Shin-Rulu-A, a diagnosis of drug-induced pneumonitis was made. However the responsible ingredient was not established, because lymphocyte stimulation tests for each ingredient in Shin-Rulu-A were negative. To the best of our knowledge, this is the second report of Shin-Rulu-A-induced pneumonitis in Japan.

[A case of Legionnaires' disease with abnormal neurological findings showing the corpus callosum abnormality on brain MRI].

A 47-year-old man was admitted to our hospital because of dysarthric speech and high fever. His brain magnetic resonance imaging (MRI) showed high intensity in the splenium of the corpus callosum (SCC) on diffusion-weighted and FLAIR imaging. His chest CT showed ground-glass attenuation in bilateral lung upper lobes, and consolidation in the right lower lobe. Because of his neurological findings and radiographic imaging, we started antibiotic therapy using quinolone, which is effective for Legionellosis. Later, Legionella species were identified by sputum culture. Pneumonia was relieved after antibiotic therapy and in parallel with clinical improvement, and the MRI findings also resolved. We report a patient who showed abnormal neurological findings and abnormality on brain MRI, both of which were reversible, in the setting of acute Legionnaires' disease.

[Management of difficult-to-treat asthma using a flow sheet for systematic evaluation and therapeutic intervention].

BACKGROUND: Although most patients of asthma can be controlled by inhaled corticosteroid (ICS), some patients remain uncontrolled even after the introduction of ICS treatment. In management of such difficult-to-treat asthma, systematic review including additional differential diagnosis and avoidance of exacerbating factors is very important. METHODS: Here we postulate a flow sheet presenting an algorithm which intends to achieve better asthma control following ATS refractory asthma guidance. For patients with poor controlled asthma even after using ICS more than moderate dose, we used the sheet in our daily outpatient management and investigated whether we could improve the control in such patients. The sheet was constructed by an algorithm which included (1) reevaluation of inhalation technique of ICS; (2) additional differential diagnosis of COPD and other similar diseases; and (3) reevaluation of presence of exacerbating factors. RESULTS: In our outpatient department, seven clinicians managed 22 difficult-to-treat asthma patients using this sheet. Additional factors which might worsen asthma control could be detected in 21 patients (95.5%). Firstly, smoking was disclosed in 8 patients (36.4%). Secondly, keeping pets was identified in 7 patients (31.8%). 5 patients (22.7%) were diagnosed as COPD rather than asthma and 4 patients (18.2%) were diagnosed as having rhinosinusitis. Some improvement of asthma control was achieved in 9 patients (40.9%). CONCLUSIONS: Reevaluation of refractory asthma patients using our newly developed flow sheet is essential and it may facilitate understanding of management of difficult-to-treat asthma.

[A case of Behçet disease with multiple nodular shadows and aneurysm of the brachiocephalic trunk caused by necrotizing vasculitis].

A 36-year-old man was admitted to our hospital in 1994 because of fever, and abdominal CT showed multiple low-density areas in the liver. Although granulomas were found in a liver biopsy specimen, a definitive diagnosis could not be established. With complaints of oral and genital ulcerations and erythema nodosum, Behçet disease was diagnosed in 1995 and he was treated with colchicine and cyclosporin. In May 1997 he had fever, leg edema, and proteinuria, and a renal biopsy revealed secondary amyloidosis. Cavitary lesions were found on a chest X-ray for the first time, but these later disappeared spontaneously. In October 2002, nodular shadows, cavitary lesions, and a mediastinal tumor appeared on a chest X-ray film. The nodular shadows in the lung fields had transformed into cavity lesions, resulting in the disappearance of the shadows. Specimens obtained from an open lung biopsy showed necrotizing granulomas and destructive vasculitis of the lung, and aneurysm of the brachiocephalic trunk caused by destructive vasculitis. Because multiple nodular shadows with cavitary lesions in Behçet disease, as in this case, have never been reported, we think this is a rare case.