Recombinant human thrombomodulin in the treatment of acute myeloid leukemia patients complicated by disseminated intravascular coagulation: retrospective analysis of outcomes between patients treated with heparin and recombinant human thrombomodulin therapy.

BACKGROUND: Recombinant thrombomodulin (rTM) is a promising anticoagulant. Improvements in disseminated intravascular coagulation (DIC) and the amelioration of bleeding complications in DIC patients were reported to be greater with rTM therapy than with unfractionated heparin therapy. However, it remains unknown whether rTM therapy affects the outcomes of patients with acute myeloblastic leukemia (AML). DESIGN AND METHOD: We retrospectively analyzed 103 patients with AML and compared outcomes between patients treated with low molecular weight heparin therapy and rTM. The diagnostic criteria for DIC were previously proposed by the Japanese Ministry of Health and Welfare. Comparisons between qualitative variables were carried out using the χ(2) test. Survival probabilities were estimated by the Kaplan-Meier method, and differences in survival distributions were evaluated using the log-rank test. RESULTS: Forty-seven patients developed DIC due to chemotherapy or their disease status. Fourteen patients were treated with rTM, while 33 patients were treated with low-molecular-weight heparin (LMWH). The log-rank test revealed that overall survival was significantly worse in the DIC group than in the non-DIC group (P=0.003), and was signfiacntly better in the rTM group than the LMWH group (P=0.016). CONCLUSION: rTM was more efficient than LMWH because of the improvements it induced in overall survival.

Advance directives in Japanese nursing homes.

CONTEXT: Advance directives are poorly understood in Japanese nursing homes. In April 2006, additional funding for end-of-life care became available as the first support for terminal care at Japanese nursing homes. OBJECTIVES: The objectives of this study were to investigate the adoption of advance directives by Japanese nursing homes, the effect of additional funding for end-of-life care in nursing homes from long-term care insurance on the use of advance directives, and the types of directives used. METHODS: A nationwide questionnaire survey of nursing homes was performed in Japan. The participants were 913 nursing homes. We investigated the prevalence of advance directives, details of the directives, and demographic data of the responders. RESULTS: Advance directives were used in 58.4% of nursing homes. The timing of introduction of the directives and the results of multivariate analysis at the facility level suggested a relation between the availability of additional funding for end-of-life care and the adoption of advance directives. Most nursing homes used instructional directives, especially directives providing an explanation and informed consent for end-of-life care in the nursing home. CONCLUSION: More than half of Japanese nursing homes have introduced advance directives, and additional funding for end-of-life care is related to their introduction. Most nursing homes have adopted instructional directives, especially those providing an explanation and informed consent regarding end-of-life care at the nursing home.

Ranimustine, ifosfamide, procarbazine, dexamethasone, and etoposide therapy for central nervous system recurrence of diffuse large B-cell lymphoma in patients with poor performance status: a pilot study.

The prognosis of patients with diffuse large B-cell lymphoma with central nervous system (CNS) involvement is still poor. We performed a pilot study to establish treatment for patients who had refractory or recurrent CNS involvement without employing high-dose chemotherapy or stem cell support. Eight patients with diffuse large B-cell lymphoma and CNS disease after first-line chemotherapy were enrolled. They were treated with MIND-E therapy (ranimustine, ifosfamide, procarbazine, dexamethasone, and etoposide) every 4 weeks. Three patients achieved complete remission, two patients achieved partial remission, and three patients did not respond. One patient received an autologous peripheral stem cell transplant after MIND-E therapy. Three patients are still alive. In conclusion, MIND-E therapy was effective for CNS disease in patients with B-cell lymphoma who were judged to be poor candidates for intensive chemotherapy. Its toxicity was tolerable. A prospective study should be done to confirm the efficacy of this regimen.

[National study on acceptance by Japanese nursing homes of patients with feeding tubes].

AIM: This study describes the acceptance of patients with feeding tubes in nursing homes for the elderly. METHODS: We sent questionnaires to 1,438 nursing homes in 2006-7 asking how many patients with feeding tubes the nursing homes had and how many new patients with feeding tubes they would accept in the future. RESULTS: The response rate was 63.6%. We analyzed the data of 735 nursing homes. The median range (25-75%) of the number of patients, patients accepted, and total number of patients currently resident was determined. The percentage of tube feedings to total beds in those categories was 8.0% (range 4.0-13.3), 5.0% (0-10.0), and 13.3% (8.0-23.8), respectively. Whereas 6% of the nursing homes had no limits on acceptance of patients with feeding tubes, 27.2% of the nursing homes replied that they would no longer accept such patients. Factors associated with restricted acceptance included nurse responses (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.30-0.95), a facility with over 100 beds (OR 2.14, 95% CI 1.10-4.17), and no current patients with feeding tubes (OR 4.19, 95% CI 2.36-7.43). CONCLUSION: One quarter of nursing homes for the elderly in Japan replied that they would no longer accept patients with feeding tubes. More nurses than other professionals replied that they would accept patients with feeding tubes. Larger nursing homes were less likely to accept tube-feeing patients. Furthermore, nursing homes with no tube-feeding patients were unwilling to accept such patients.

The nursing home versus the hospital as the place of dying for nursing home residents in Japan.

OBJECTIVES: To determine the characteristics of nursing home residents that are associated with dying in a nursing home versus a hospital in Japan. DESIGN: Retrospective case-control study. SETTING: A nonprofit nursing home with 110 beds in Tokyo, Japan. PARTICIPANTS: Eighty-six nursing home residents who died in the nursing home (n=43) or in a hospital (n=43) between 1 April 1999 and 30 September 2004. MEASUREMENTS: Nursing home records were reviewed to gain information regarding the following domains: demography, the family decision-maker, health status, resident and family preference for nursing home end-of-life care, and presence of a full-time physician. RESULTS: The variables older age [adjusted odds ratio (adjusted OR)=1.08, 95% confidence interval (95% CI)=1.01-1.17], the family decision-maker's preference for nursing home end-of-life care (adjusted OR=3.95, 95% CI=1.21-12.84), and presence of a full-time physician (adjusted OR=3.74, 95% CI=1.03-13.63) were associated with dying in the nursing home. CONCLUSION: Older age, the family's preference for nursing home end-of-life care, and the presence of a full-time physician were significantly related to dying in the nursing home versus in a hospital.