[Continuous Subcutaneous Injection Therapy in End-of-Life Symptoms of Cancer and Non-Cancer Patients].

The significance of continuous subcutaneous injection(CSI)therapy was assessed in end-of-life symptoms of cancer and non-cancer home hospice patients. In a retrospective analysis of 106 advanced cancer patients who underwent opioid CSI therapy, the most frequent symptom was pain(65%), followed by dyspnea(46%), seizure(8%), ileus(8%), and other uncontrolled end-of-life symptoms(23%). The median oral morphine equivalent daily opioid dose was 90 mg(2.5-1,920 mg)and the median duration of CSI administration was 3 days(1-350 days). Eighty-six percent of the patients underwent adjunct therapy to opioids, such as midazolam, octreotide, and haloperidol, in the management of cancer pain and non-pain cancer symptoms. In 5 non-cancer patients with systemic vascular disease, various symptoms required opioid CSI in the endof- life days. CSI with adjunct therapy to opioids can be effective in the treatment of end-of-life symptoms in both cancer and non-cancer patients.

[Cancer Disease Trajectory and the Contribution of Artistic Outreach Activity to Palliative Care].

The purpose of this article is to show some unintentional aspects of palliative supports offered by the community. The activities of the Opera Ehime, an amateur opera group, play an important role in palliative and grief care. This community is also committed to providing supportive care for home hospice cancer patients through an outreach music program that offers patients connection with others and reduces isolation. Assessment by the coordinator includes determiningthe patients' preferences and the relevance of music throughout their lives. Then, the coordinator predicts the cancer trajectory and invites patients to participate in the home hospice concert at any stage of their illness. These activities are an effective form of supportingcancer care for patients to promote wellness and improve physical and emotional well-being, as well as quality of life.

Transumbilical arterial embolization of a large dural arteriovenous fistula in a low-birth-weight neonate with congestive heart failure.

PURPOSE: The purpose of this study was to report transumbilical arterial embolization of a large dural arteriovenous fistula (AVF) in a low-birth-weight neonate with congestive heart failure (CHF). CASE PRESENTATION: A female neonate was delivered by cesarean section at 31 weeks of gestation. Her birth weight was 1538 g and Apgar scores were 6 at both 1 and 5 min. Because of dyspnea and retracted respiration immediately after birth, she required mechanical ventilation. Ultrasound revealed right cardiac overload and a large cystic mass at the posterior brain. Magnetic resonance imaging on day 1 showed a large dural AVF (dural sinus malformation with arteriovenous (AV) shunts) at the torcular herophili. Umbilical artery and vein catheterization were performed on the same day for neurointervention. CHF prompted emergency embolization on day 8. The transfemoral arterial route could not be used because of its small size and compromised femoral artery blood flow. Transumbilical arterial embolization shrank the AV shunts markedly, resulting in clinical improvement, thus requiring no further intervention. Follow-up angiography at 4 months confirmed no residual AVF. Her growth and development were normal at the last follow-up at age 4 years. CONCLUSION: This patient apparently was the lowest birth weight neonate with a large AVF successfully treated by embolization, which is usually performed through the transfemoral arterial route. The transumbilical arterial route is an alternative for neonates with birth weight <2000 g and very small femoral arteries.

[Support for cancer caregivers during the palliative, hospice, and bereavement phases: the role of family physicians].

The family caregivers of cancer patients are at an increased risk of physical and mental morbidity. The purpose of this study is to capture the needs of the caregivers before and during the years after the loss of the patient. A survey was conducted among 229 consecutive advanced cancer patients in our family clinic. Seventy percent of the patients died in their homes, the median overall survival was 15.1 months, and the median survival time was 3 months from the beginning of the coordination with oncologists. While 28%of the patients received the best possible supportive care alone and 50%of them were admitted after the cessation of chemotherapy, in 22%of the patients, the coordination with oncologists began during the chemotherapy phase. During times of active cancer treatment, the caregivers were provided with various types of support from the family physicians. In the post-death bereavement phase, 124 caregivers were admitted to our family care clinic. The family physician can play an important role in aiding the caregivers during the palliative, hospice, and bereavement phases.

[Effective methods of organizing complex information in advanced cancer patients].

Advanced cancer patients often present with variable clinical information documenting widespread lesions and treatment histories. For health care providers, organizing and managing this information is crucial. In our ambulatory and home palliative/ hospice care practice, two visual tools are used: 1 ) a one-page line diagram which shows the Edmonton Labeled Visual Information System (ELVIS) and a schematic demarcation of dermatomes shown as distinct segments, and 2 ) a one-page summary report containing various graphs displaying the transition of clinical variables which appear to be predictive of survival. These concise visual representations of cancer information can be beneficial for summarizing or reviewing the disease and its clinical course, and in the transfer of patient information to other institutions. They may also serve as an aid to improve information recall in cancer patients, as well as to provide both the patients and their caregivers with information about cancer trajectories so that they can set appropriate goals, priorities, and expectations of care.

Alveolar epithelial cells: differentiation and lung injury.

Re-epithelialization of alveolar epithelial cells is one of the important repair processes in many types of lung injury. The major functions of alveolar type II cells are synthesis and secretion of surfactant, hyperplasia in reaction to alveolar epithelial injury, and serving as progenitor cells for alveolar type I cells. The authors have examined the effects of several soluble factors on cultured alveolar type II cells in vitro, and also examined the histopathology and gene expression of surfactant proteins in the rat lungs with LPS, bleomycin and/or treated with keratinocyte growth factor. The authors next examined the effects of bone marrow stromal cells (BMSC) implanted transvenously into bleomycin-induced lungs. The authors found that keratinocyte growth factor (KGF) is a strong growth factor for alveolar type II cells, and that KGF instillation prevents bleomycin-induced lung injury. Furthermore, the authors showed the possibility of differentiation of implanted BMSC into alveolar epithelial cells. KGF and BMSC may play an important role in maintaining the alveolar epithelium and repairing the damaged epithelium after injury, and may well provide potential therapeutic alternatives.

Role of surgery in the patients with stage I and II primary gastric lymphoma.

BACKGROUND/AIMS: Primary gastric lymphoma is a relatively rare disease. As the concept of MALT (mucosa-associated lymphoid tissue) lymphoma has been acknowledged, a relation between primary gastric lymphoma and Helicobacter pylori infection seems apparent, appropriate treatment, including surgical resection, and/or chemotherapy, and/or radiotherapy has remained controversial. METHODOLOGY: Between 1974 and 1996, we treated 85 Japanese patients with histologically proven primary gastric lymphomas (stage I and II according to modified Ann Arbor staging) with surgery, and/or adjuvant chemotherapy. The clinicopathological factors, especially regarding surgical curability and survival were evaluated retrospectively. RESULTS: Of the 85 patients (44 men, and 41 women), average age was 60.5 years. The lesion was frequently located at the middle third of the stomach, and multiple lesions were noted in 19 patients. Microscopic lymph node metastasis was positive in 37.6% (32/85), and the rate of positive metastasis increased in proportion to depth of invasion. There was a discrepancy between macro- and microscopic findings regarding lymph node metastasis. Total gastrectomy was done for 50 patients, distal gastrectomy for 31, pancreatoduodenectomy for 3, and gastrojejunostomy for 1 patient. Lymph node dissection was done at the D1,2 level for 73, and at the D3 level for 12 patients. There were no major complications except in 3 cases (subphrenic abscess), and there was 1 operative death. The overall 5-year survival and 10-year survival was 82.3% and 74.0%, respectively. In the stage I patients, the 5-year and 10-year survival rate was 97.5%, respectively. All cases of surgery were curative, and surgery alone resulted in the same survival time as the surgery plus chemotherapy group (10-year survival; 100% vs. 96.6%, no statistical difference). In the stage II patients, 5-year and 10-year survival rates were 58.6% and 44.2%, respectively. Surgery was curative in 59.3% (19/32), and palliative in 40.7% (13/32). Palliative surgery was done because of extensive lymph node metastasis in 6 patients, invasion to adjacent organ in 6, and both in 1 patient. Chemotherapy was prescribed in 71.9% of the patients (23/32), and when compared with the patients who were on chemotherapy, the survival rate showed no statistical difference regardless of palliative or curative surgery. CONCLUSIONS: Surgery for primary gastric lymphoma had low complication rate, and led to good survival rate in stage I disease. In stage II disease, surgical curability did not affect the survival, implying the necessity of the evaluation about the treatment strategy by randomized study. However, considering the stage migration before and after and possible inaccuracy of preoperative staging, the application of non-surgical treatment must be prudent.