The effect of palliative care team intervention and symptom improvement using patient-reported outcomes: a multicenter prospective observational study.

PURPOSE: Hospital-based palliative care teams (HPCTs) are widespread internationally, but multicenter studies about their effectiveness, using patient-reported outcomes (PROs), are limited to Australia and a few other countries. We conducted a multicenter, prospective observational study in Japan to explore the effectiveness of the HPCTs using PROs. METHODS: Nationwide, eight hospitals participated in the study. We included newly referred patients for one month in 2021 and followed them for one month. We asked the patients to complete the Integrated Palliative Care Outcome Scale or the Edmonton Symptom Assessment System as PROs at the time of the intervention, three days later, and weekly after the intervention. RESULTS: A total of 318 participants were enrolled, of whom 86% were patients with cancer, 56% were undergoing cancer treatment, and 20% received the Best Supportive Care. After one week, the following 12 symptoms showed more than a 60% improvement from severe to moderate or less: vomiting (100%), shortness of breath (86%), nausea (83%), practical problems (80%), drowsiness (76%), pain (72%), poor sharing of feelings with family or friends (72%), weakness (71%), constipation (69%), not feeling at peace (64%), lack of information (63%), and sore or dry mouth (61%). Symptoms with improvement from severe/moderate to mild or less were vomiting (71%) and practical problems (68%). CONCLUSION: This multicenter study showed that HPCTs effectively improved symptoms in several severe conditions, as assessed by PROs. This study also demonstrated the difficulty of relieving symptoms in patients in palliative care and the need for improved care.

Disposal practices for unused and expired medications: pilot data from three cities in three countries.

Objective: To collect pilot data on medication disposal practices of unused and expired medications from three cities in three countries. Methods: A cross-sectional survey was conducted in Pittsburgh, United States (US); Turin, Italy; and Kobe, Japan. A convenience sampling was utilized through drug take-back programs in Pittsburgh, US; pharmacy customers in Turin, Italy; and pharmacy students and family members in Kobe, Japan. Descriptive analysis was conducted to assess medications disposal practices including attitudes and beliefs of respondents. Results: The sample included 342 respondents [99 (Pittsburgh, US); 168 (Turin, Italy); and 75 (Kobe, Japan)]. The mean unused and expired medications per patient for Pittsburgh, US was (1.60±2.30 and 0.51±1.54); Turin, Italy (1.69±1.86 and 0.49±1.22) and Kobe, Japan (6.69±8.78 and 0.84±2.26). The major reason for unused medications in Pittsburgh, US (31.3%) was "Medication was as needed"; in Turin, Italy (28.0%) "No longer suffer from the condition"; and in Kobe, Japan (54.7%) "No longer suffer from the condition". The most common reason for expired medications was "No longer suffer from the condition" (Pittsburgh, US 17.2%; Turin, Italy 15.5%; Kobe, Japan 12.0%). The disposal method in Pittsburgh, US was disposing in the toilet (35.4%); returned to the pharmacy in Turin, Italy (51.2%); and disposed the original container in the trash in Kobe, Japan (82.7%). Conclusions: There is a need for counseling protocols regarding proper disposal, which can lead to better adherence, reduction of prescription drug abuse, and less environmental hazards due to improper disposal of prescription medications.

Comparison of the Effects of Diuretics on Pedal Edema in Patients with Cancer.

Background: The effectiveness of tolvaptan (T) for treating pedal edema remains unknown. Objective: We aimed to clarify the effectiveness of diuretics, including T, on pedal edema in advanced cancer patients, and to compare patients' versus physicians' assessments of the effects. Methods: Participants comprised 88 hospitalized cancer patients treated with T, loop diuretics (L), or spironolactone (S). Patient characteristics, initial doses of diuretics, reason for discontinuation, side effects, evaluation of pedal edema, and effects of diuretics on pedal edema were investigated retrospectively using electronic medical records. Results: The rates of improvement of pedal edema according to patients (Pt) and physicians (MD) were T: Pt 83.3% (n = 6), MD 71.4% (n = 14); L: Pt 57.1% (n = 14), MD 50.0% (n = 26); S: Pt 0% (n = 1), MD 57.1% (n = 7); L+S: Pt 83.3% (n = 12), MD 69.0% (n = 29); T+L: Pt 90.9% (n = 22), MD 71.8% (n = 39); T+S: Pt 0% (n = 1), MD 0% (n = 2); T+L+S: Pt 62.5% (n = 8), MD 69.2% (n = 13). In 57.1%-90.9% and 50.0%-71.8% of episodes, patients and physicians, respectively, observed some effectiveness of diuretics on pedal edema in advanced cancer, except for in the S (Pt) and T + S (Pt, MD) groups. Conclusions: The treatment of pedal edema improves patient symptoms, enhancing quality of life. Further verification and evaluation of the effect of T on pedal edema are needed.

Cross-cultural Comparison of Pharmacy Students' Attitudes, Knowledge, Practice, and Barriers Regarding Evidence-based Medicine.

Objective. To explore cultural influences on US and Japanese pharmacy students' evidence-based medicine (EBM) attitudes, knowledge, and behavior. Methods. A cross-sectional study was conducted using a self-administered survey. Senior students in one pharmacy school in the United States and two pharmacy schools in Japan were invited to complete a 33-item survey instrument. Results. Students in both countries reported having positive attitudes and understanding of EBM concepts. In their self-evaluation, American students rated their current EBM practice, EBM skills, and access to EBM resources higher than Japanese students rated themselves in these areas. The most common barriers to EBM for American students were lack of time (84.5%), lack of statistical knowledge (63.9%), and lack of critical appraisal skills (53.1%). The most common barriers to EBM for Japanese students were lack of training (92.6%), lack of clinical knowledge (90.4%), and lack of opportunity (88.8%). Conclusion. Although barriers to implementing EBM and confidence levels in using EBM differed between US and Japanese pharmacy students, both cohorts recognized EBM as an important skillset for the pharmacy profession. Culturally specific approaches to teaching EBM to pharmacy students are needed to improve EBM use in practice.

Can milnacipran used for neuropathic pain in patients with advanced cancer cause neuromuscular and somatosensory disorders?

BACKGROUND: Milnacipran is one of the classes of drugs that are serotonin and norepinephrine reuptake inhibitors (SNRIs). It is a promising drug for the treatment of neuropathic pain in patients with advanced cancer. However, we found that neuromuscular and somatosensory disorders occurred when milnacipran was used as an adjuvant analgesic. CASE REPORT: A 66-year-old woman with a history of neuropathic pain was given 15 mg of milnacipran after dinner. The next morning she developed stiffness of the fingers, numbness in the mandible, and the soles of her feet felt swollen. Milnacipran was discontinued and her symptoms disappeared immediately. We managed this case, which was becoming severe, by discontinuing milnacipran on early detection of symptoms. DISCUSSION: This is the first report that demonstrates an adverse reaction of milnacipran when used as an analgesic adjuvant, and not as an antidepressant drug, for neuropathic pain in patients with advanced cancer. The analgesic effect of SNRIs will likely be used in the management of neuropathic pain in the future; however, clinicians should be aware of the early adverse reactions to these agents.

Can anti-infective drugs improve the infection-related symptoms of patients with cancer during the terminal stages of their lives?

BACKGROUND: Appropriate use of anti-infective drugs is essential in clinical practice. No evidence-based guidelines or protocols have been published on the appropriate use of anti-infective drugs in patients receiving palliative care as yet. METHODS: The medical records, which included the demographic data of patients, anti-infective drug use, bacteriologic findings, symptoms, and hematologic findings were reviewed retrospectively to determine the potential factors that contribute to symptom improvement of patients in terminal phase. RESULTS: Seventy-one patients (64%) who received anti-infective drugs and had a total of 326 episodes of infection were assessed. Symptom improvement was seen in 33.1%. A total of 22.6% of episodes were started on anti-infective drugs during the last week of life and the symptom improvement in these episodes was 9.2%. Symptom improvement was hardly observed when the anti-infective drug was administered during the last week of life. The association between the decrease in the C-reactive protein (CRP) levels, the decrease of the leukocyte count, reduction of fever, and symptom improvement was determined. The decrease of CRP levels was 42.4%; leukocyte, 56.7%; and reduction of fever was 28.4%. The symptom improvement of individual treatment history was also investigated. The symptom improvement of the group who took positive treatment such as chemotherapy, radiotherapy, surgery, and catheter placement was significantly lower than that of no-treatment group. CONCLUSIONS: Active cancer treatment probably induces the symptoms related to infection and the use of anti-infective drugs. Unnecessary and excessive treatment should be avoided, and the symptoms should be managed with consideration of the patient's state of mind in order to improve the quality of life of terminally ill patients.