Is there any relationship between nurses' perceived organizational justice, moral sensitivity, moral courage, moral distress and burnout?

AIM: The present study is an attempt to investigate the relationship between Corley's model variables in mental health nurses. BACKGROUND: Based on Corley's model, burnout and moral distress in nurses are, in retrospect, the consequences of the interplay of organizational and individual factors such as perceived organizational justice, moral sensitivity, and moral courage. The relationship between two variables or three variables of Corley's moral distress model has been investigated, but the test of Corley's moral distress model with more variables has not been done. Therefore, this research was proposed with the aim of investigating the relationship between the variables of moral courage and moral sensitivity (as characteristics of nurses), perceived organizational justice (as an antecedent), moral distress, and job burnout (as consequences of moral distress). METHODS: The study was conducted as a descriptive correlational study involving 500 nurses working in the mental health wards of hospitals. Data collection was conducted using perceived organizational justice scale, moral sensitivity scale, moral courage scale, moral distress scale, and burnout inventory. RESULTS: The results showed a significant relationship between perceived organizational justice, moral sensitivity, moral courage, and moral distress (< 0.05). Moreover, perceived organizational justice and moral distress had an inverse relationship. Moral sensitivity and moral courage had a direct relationship with moral distress (< 0.05). Furthermore, the results showed inadequate model fitness. CONCLUSIONS: This study adds to the existing knowledge about the experiences of mental health nurses and their interactions with both organizational and individual factors. It highlights that the connections between perceived organizational justice, moral sensitivity, moral courage, moral distress, and burnout are intricate and multifaceted. As we deepen our understanding of these relationships, it opens the door for the development of interventions and strategies to enhance nurses' well-being and the quality of care they deliver in mental health settings. Moreover, future research and ongoing refinement and expansion of Corley's model will be crucial in addressing the complex challenges within the healthcare sector.

Grounds for surrogate decision-making in Japanese clinical practice: a qualitative survey.

BACKGROUND: In the coming years, surrogate decision-making is expected to become highly prevalent in Japanese clinical practice. Further, there has been a recent increase in activities promoting advance care planning, which potentially affects the manner in which judgements are made by surrogate decision-makers. This study aims to clarify the grounds on which surrogate decision-makers in Japan base their judgements. METHODS: In this qualitative study, semi-structured interviews were conducted to examine the judgement grounds in surrogate decision-making for critical life-sustaining treatment choices in acute care hospitals. RESULTS: A total of 228 participants satisfied the inclusion criteria, and 15 were selected for interviews. We qualitatively analysed the content of 14 interview transcripts, excluding one that did not meet the inclusion criteria. Based on this analysis, we extracted 4 core categories, 17 categories, 35 subcategories, and 55 codes regarding judgement grounds in surrogate decision-making. The four core categories were as follows: patient preference-oriented factor (Type 1), patient interest-oriented factor (Type 2), family preference-oriented factor (Type 3), and balanced patient/family preference-oriented factor (Type 4). The Type 4 core category represented attempts to balance the preferences of the patient with those of the surrogate decision-maker. CONCLUSIONS: Surrogate decision-makers based their decisions on important aspects related to a patient's life, and they considered not only the patient's preferences and best interests but also their own preferences. As the need for surrogate decisions will increase in the future, decision-makers will need to consider judgement grounds from a more diverse perspective.

Psychometrics of the moral distress scale in Iranian mental health nurses.

BACKGROUND: One of the challenges that nurses often face in ethical decision-making situations is moral distress. Moral distress is caused by the conflict between professional and individual values in decision-making situations. Despite its importance, there is no reliable scale in Persian to measure it. Therefore, this study was conducted to validate the moral distress scale in mental health nurses in Iranian culture and Persian language. METHODS: This study was conducted in two parts: Translation and cross-cultural adaptation and psychometric analysis. The translation and cross-cultural adaptation process was conducted based on the Polit approach. Next, face validity (qualitative), content validity (quantitative and qualitative), and construct validity were examined. This part of the study was a cross-sectional study. In this step, a demographic questionnaire and the Moral Distress Scale were sent to 500 nurses working in selected educational and medical centers in Iran via online questionnaires. Then, the construct validity of the "Moral Distress Scale" was confirmed by confirmatory factor analysis and the reliability of the instrument was examined by studying the internal consistency with Cronbach's alpha and the internal correlation of the AIC. RESULTS: The confirmatory factor analysis showed an acceptable ratio of the expressions in 15 items in three factors: Acquiescence to patients' rights violations (6 items), Unethical conduct by caregivers (5 items), and low staffing (4 items) in the scale. The internal consistency of the instrument with Cronbach's alpha was higher than 7.0. CONCLUSION: The Persian version of moral distress with 15 items of the three factors had validity and reliability. According to the present findings, this scale can be used to study moral distress among nurses working in psychiatric wards. Moral distress leads to burnout, increases risks to patient safety and reduces quality of care. Nurses need to be able to assess and manage moral distress. Therefore, considering the side effects, it is necessary to have a reliable and valid scale that can be studied. Considering that culture has an impact on nurses' moral distress, it is suggested that this instrument be studied in and tested in other languages and cultures.

Are Intraoral Stents Effective for Reducing the Severity of Oral Mucositis During Radiotherapy for Maxillary and Nasal Cavity Cancer?

PURPOSE: The intraoral stent (IOS) is an individualized mouth opening device that can be used during radiotherapy (RT) for head and neck cancer to prevent unnecessary irradiation to normal tissues. The purpose of the present study was to compare the severity of oral mucositis (OM) between patients using and not using an IOS during RT for maxillary and nasal cavity cancer. PATIENTS AND METHODS: We designed and implemented a retrospective cohort study. The study sample included patients with maxillary and nasal cavity cancer who had undergone RT. The primary predictor variable was IOS application, and the outcome variable was the grade of OM. RESULTS: The IOS group included 18 patients with an IOS and the control group, 16 patients without an IOS. The parameters of the dose-volume histogram included the median dosage covering 1 mL (D1mL) for the tongue and the mean dosage. The D1mL (36.2 vs 65.4 Gy) and mean dosage (4.9 Gy vs 25.9 Gy) were both significantly lower in the IOS group than in the control group (P < .005). The incidence of OM using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0, were significantly different between the oral stomatitis grade and the use of an IOS (P = .028). A significant difference was found in opioid use between the IOS and control groups (P = .009). CONCLUSIONS: The use of an IOS decreased the radiation dosage to the tongue, the grade of OM, and opioid usage during RT.

The role of online ethics consultation on mental health.

BACKGROUND: Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice. RESEARCH OBJECTIVE: To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness. ETHICAL CONSIDERATIONS: The research was conducted in accordance with the Declaration of Helsinki. RESEARCH DESIGN: This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan. PARTICIPANTS: The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users. FINDINGS: The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive. DISCUSSION: The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants. CONCLUSION: This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses' moral distress, building ethics into decision-making.

Impact of moral sensitivity on moral distress among psychiatric nurses.

BACKGROUND: Moral distress occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. Moral distress was found to cause negative feelings, burnout, and/or resignation. Not only external factors such as lack of staff but also internal ones affect moral distress. Moral sensitivity, which is thought of as an advantage of nurses, could effect moral distress, as nurses being unaware of existing ethical problems must feel little distress. OBJECTIVES: To examine the impact of moral sensitivity on moral distress among psychiatric nurses, and affirm the hypothesis that nurses with higher moral sensitivity will suffer moral distress more than nurses with less moral sensitivity in two different samples. ETHICAL CONSIDERATION: The study obtained ethical approval from the Research Ethics Committee of the Faculty of Medicine at Mie University (# 1111, 20.4.2010), and by the Turku University Ethics Board (29.5.2012). Permissions to undertake the study was obtained from the in two hospital districts and in one city (§ 48/4.10.2012, § 63/4.9.2012, 51/2012 27.8.2012). Informed consent was not formally obtained, because the questionnaire was anonymously reported by the participants who volunteered to answer. The participants responded voluntarily and anonymously. METHODS: An anonymous questionnaire containing the Revised Moral Sensitivity Questionnaire and the Moral Distress Scale for Psychiatric nurses was conducted to 997 nurses in 12 hospitals in Japan, and 974 nurses in 10 hospitals in Finland after obtaining of approval by research ethics committees. Data were analyzed using a multi-group structural equation model analysis. FINDINGS: A set of analyses imply that the association of moral sensitivity with moral distress is significant and similar between Japan and Finland, whereas the factor structures of moral sensitivity and moral distress may be partially different. DISCUSSION: The result of this study may indicate that nurses with high moral sensitivity can sense and identify moral problems, but not resolve them. Therefore, supporting nurses to solve ethical problems, not benumbing them, can be important for better nursing care and prevention of nurses' resignation. CONCLUSION: Moral sensitivity and moral distress were positively correlated among psychiatric nurses in both Japan and Finland, although the participating nurses from the two countries were different in qualification, age, and cultural background. Nurses with high moral sensitivity suffer from moral distress.

Long-term outcomes of proton beam therapy in patients with previously untreated hepatocellular carcinoma.

Long-term efficacy of proton beam therapy (PBT) remains unclear for patients with previously untreated hepatocellular carcinoma (HCC). We aimed to study the long-term outcomes of PBT according to Barcelona Clinic Liver Cancer (BCLC) staging classifications in patients with previously untreated HCC. The major eligibility criteria of this observational study were an Eastern Cooperative Oncology Group performance status (PS) 0-2, Child-Pugh grade A or B, previously untreated HCC covered within an irradiation field, and no massive ascites. A total of 66.0-77.0 GyE was administered in 10-35 fractions. Local tumor control (LTC), defined as no progression in the irradiated field, progression-free survival (PFS), and overall survival (OS) were assessed according to BCLC staging. From 2002 to 2009 at our institution, 129 patients were eligible. The 5-year LTC, PFS, and OS rates were 94%, 28%, and 69% for patients with 0/A stage disease (n = 9/21), 87%, 23%, and 66% for patients with B stage disease (n = 34), and 75%, 9%, and 25% for patients with C stage disease (n = 65), respectively. The 5-year LTC and OS rates of 15 patients with tumor thrombi in major vessels were 90% and 34%, respectively. Multivariate analyses revealed that PS (0 versus 1-2) was a significant prognostic factor for OS. No grade 3 or higher adverse effects were observed. PBT showed favorable long-term efficacies with mild adverse effects in BCLC stage 0 to C, and can be an alternative treatment for localized HCC especially when accompanied with tumor thrombi. This study was registered with UMIN Clinical Trials Registry (UMIN000025342).

Registration error of the liver CT using deformable image registration of MIM Maestro and Velocity AI.

BACKGROUND: Understanding the irradiated area and dose correctly is important for the reirradiation of organs that deform after irradiation, such as the liver. We investigated the spatial registration error using the deformable image registration (DIR) software products MIM Maestro (MIM) and Velocity AI (Velocity). METHODS: Image registration of pretreatment computed tomography (CT) and posttreatment CT was performed in 24 patients with liver tumors. All the patients received proton beam therapy, and the follow-up period was 4-14 (median: 10) months. We performed DIR of the pretreatment CT and compared it with that of the posttreatment CT by calculating the dislocation of metallic markers (implanted close to the tumors). RESULTS: The fiducial registration error was comparable in both products: 0.4-32.9 (9.3 ± 9.9) mm for MIM and 0.5-38.6 (11.0 ± 10.0) mm for Velocity, and correlated with the tumor diameter for MIM (r = 0.69, P = 0.002) and for Velocity (r = 0.68, P = 0.0003). Regarding the enhancement effect, the fiducial registration error was 1.0-24.9 (7.4 ± 7.7) mm for MIM and 0.3-29.6 (8.9 ± 7.2) mm for Velocity, which is shorter than that of plain CT (P = 0.04, for both). CONCLUSIONS: The DIR performance of both MIM and Velocity is comparable with regard to the liver. The fiducial registration error of DIR depends on the tumor diameter. Furthermore, contrast-enhanced CT improves the accuracy of both MIM and Velocity. INSTITUTIONAL REVIEW BOARD APPROVAL: H28-102; July 14, 2016 approved.

Periostin is a negative regulator of mineralization in the dental pulp tissue.

The dental pulp tissue is encased in hard tissue and surrounded by hard tissue-forming cells, but remains in a non-mineralized state itself, suggesting the presence of regulatory mechanisms precluding pulp mineralization. This study aimed to reveal the regulatory function of periostin (Postn), which is essential for osteoblast differentiation, for odontoblast differentiation/mineralization. We evaluated the effects of Postn overexpression and RNAi-mediated suppression in mouse dental papilla cells (MDPs) on the expression of odontoblastic markers and Notch signaling molecules, and on the formation of mineralized nodules. Localization of Postn in the dental pulp tissue of normal and cavity-prepared molars was observed immunohistologically. Enforced overexpression of Postn in MDPs induced down-regulation of odontoblastic markers and in vitro mineralization. Conversely, silencing of Postn mRNA in MDPs induced up-regulation of odontoblastic markers and ALP activity. Up- and down-regulation of Postn caused increased and decreased expression, respectively, of Notch signaling molecules. Postn expression was minimal in normal dental pulp, but was rapidly and globally increased in the whole pulp tissue of molar teeth at 1 day after cavity preparation, decreasing thereafter. These results indicate that Postn may be a negative regulator of odontoblast differentiation/mineralization, and that may exert its actions via Notch signals.

[Concurrent proton therapy and chemotherapy for locally advanced cancers].

Charged particles such as protons and carbon-ions offer advantageous physical properties to radiation therapy (RT) for the treatment of various cancers when compared with photons, because they exhibit a spread-out Bragg peak, and may be utilized to achieve a desirable dose distribution to the target volume by using specified beam modulation. Interestingly, the cytocidal effect of protons is almost equal to that of photons, because both protons and photons are considered low-linear energy transfer radiations. Hence, proton beam therapy (PBT) is an attractive RT option, especially in the treatment of locally advanced cancers, as irradiation doses can be safely escalated while sparing the surrounding normal tissues, and because PBT may be concurrently combined with chemotherapy for treating such cancers. Recent advances in PBT techniques including a spot scanning method, as well as an increase in the number of particle therapy institutes are anticipated to yield favorable results through future multi-institutional prospective studies. The University of Tsukuba has carried out several studies to validate the effectiveness of PBT for many types of cancers since 1983. Here, we present our findings on the clinical outcomes of PBT for esophageal cancer, non-small cell lung cancer, intrahepatic biliary tract cancer, pancreas cancer, and bladder cancer; future aspects of PBT concurrently combined with chemotherapy for treating locally advanced cancers are also discussed.

Long-term follow-up of unresectable adenoid cystic carcinoma of the trachea and bronchus treated with high-dose proton beam therapy: A report of two cases.

Adenoid cystic carcinoma (ACC) of the trachea is a rare disease that is slow growing and has a risk of distant metastasis. The standard treatment for ACC of the trachea is surgery, but this tumor is often unresectable. In definitive radiotherapy using photons for unresectable ACC of the trachea, it is sometimes difficult to deliver a sufficient dose to the target without exceeding the tolerable dose to the surrounding normal tissues. Here, we report two cases of ACC of the trachea that received a high dose (74 Gy [relative biological effectiveness]) of proton beam therapy and achieved long-term survival.

A case of massive hemoptysis caused by lung cancer saved by V-V ECMO and hemostasis achieved by radiotherapy.

Massive hemoptysis is one of the fatal complications of lung cancer. There is no established standard treatment method for it, and it often causes sudden suffocation, and some cases may be difficult to save. A 63-year-old man was admitted to the hospital with dyspnea, and developed massive hemoptysis from lung cancer shortly after admission. The tumor had obstructed the right main bronchus and had invaded the right pulmonary artery. Surgery and interventional radiology were judged impossible. The patient was successfully saved by the introduction of Veno-Venous Extra Corporeal Membrane Oxygenation (V-V ECMO), and hemostasis was obtained by radiotherapy. Two months after completion of radiotherapy, he was weaned off the ventilator and discharged on his own. He died of increased peritoneal dissemination and other complications 1 year and 1 month later, but no recurrence of hemoptysis was noted until his death. We experienced a case of massive hemoptysis in which V-V ECMO and radiation therapy succeeded in saving life and stopping bleeding. The use of V-V ECMO by emergency care teams and multimodality therapy, including radiotherapy, were effective for massive hemoptysis from lung cancer.

Proton beam therapy for cervical lymph node metastasis in an octogenarian with melanoma of unknown primary: a case report.

An 80-year-old man with an approximately 3-cm mass in the right submandibular region presented to our institution. Magnetic resonance imaging revealed enlarged lymph nodes (LNs) in the right neck, and fluorine-18-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) indicated positive FDG accumulation in the right neck LNs only. Excisional biopsy was performed for suspected malignant lymphoma, and the biopsy revealed melanoma. Close examination of the skin, nasal cavity, oral pharyngeal and laryngeal cavities, and gastrointestinal tract were performed. No primary tumor was detected by these examinations, and the patient was diagnosed with cervical LN metastasis from melanoma of unknown primary of clinical stage T0N3bM0 stage IIIC. The patient refused cervical neck dissection because of his age and comorbidity of Alzheimer's disease and instead opted for proton beam therapy (PBT) at a total dose of 69 Gy (relative biological effectiveness) in 23 fractions. He did not receive any systemic therapy. The enlarged LNs shrunk slowly, and FDG PET/CT at 1 year after PBT showed that the right submandibular LN had shrunk from 27 to 7 mm in length, and there was no significant FDG accumulation. At 6 years and 4 months after PBT, the patient is alive without any recurrence.

Proton beam therapy in multimodal treatment for locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus.

BACKGROUND: To evaluate proton beam therapy (PBT) in multimodal treatment for locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus (NPSCC). METHODS: The cases in this study included T3 and T4 NPSCC without distant metastases that were treated at our center using PBT between July 2003 and December 2020. These cases were classified into 3 groups based on resectability and treatment strategy: surgery followed by postoperative PBT (group A); those indicated to be resectable, but the patient refused surgery and received radical PBT (group B); and those declared unresectable based on the extent of the tumor and treated with radical PBT (group C). RESULTS: The study included 37 cases, with 10, 9 and 18 in groups A, B and C, respectively. The median follow-up period in surviving patients was 4.4 years (range 1.0-12.3 years). The 4-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 58%, 43% and 58% for all patients; 90%, 70% and 80% in group A, 89%, 78% and 89% in group B; and 24%, 11% and 24% in group C. There were significant differences in OS (p = 0.0028) and PFS (p = 0.009) between groups A and C; and in OS (p = 0.0027), PFS (p = 0.0045) and LC (p = 0.0075) between groups B and C. CONCLUSIONS: PBT gave favorable outcomes in multimodal treatment for resectable locally advanced NPSCC, including surgery followed by postoperative PBT and radical PBT with concurrent chemotherapy. The prognosis for unresectable NPSCC was extremely poor, and reconsideration of treatment strategies, such as more active use of induction chemotherapy, may improve outcomes.

Effects of lymphopenia on survival in proton therapy with chemotherapy for non-small cell lung cancer.

Lymphocytes play an important role in the cancer immune system. In the present study, we aimed to evaluate the associations of lymphopenia during proton beam therapy (PBT) and concurrent chemotherapy with clinical outcomes and to determine whether lung or bone is more influential on lymphopenia during PBT. Data from 41 patients with stage III non-small cell lung cancer (NSCLC) who received PBT of 74 GyE with concurrent chemotherapy between 2007 and 2017 were reviewed retrospectively. The correlation between dosimetry parameters obtained from dose-volume histograms of the bone and lung and lymphopenia during PBT were analyzed. Minimum absolute lymphocyte count (ALCmin) and maximum neutrophil/lymphocyte ratio (NLRmax) were used as indicators of lymphopenia. Bone V5-20 and lung V5-50 were significantly correlated with the ALCmin and NLRmax during PBT. Multivariable analysis showed that the NLRmax, but not the ALCmin, was associated with overall survival (OS), progression-free survival (PFS) and distant metastasis-free survival (DMFS). The 3-year rates of OS, PFS and DMFS of patients with a low (≤ 6.3) versus high (> 6.3) NLRmax were 73.9% vs 44.4% (P = 0.042), 26.1% vs 5.6% (P = 0.022) and 39.1% vs 5.6% (P < 0.001), respectively. Lung V20 was significantly associated with DMFS on multivariable analyses (hazard ratio: 1.094, P = 0.008), whereas bone V5 had no impact on survival outcomes. We concluded that the NLRmax was a better prognostic indicator than the ALCmin, and the lung dose had more influence than the bone dose on the main survival outcomes in stage III NSCLC patients treated with PBT combined with concurrent chemotherapy.

Long-term Outcomes After Moderate Hypofractionated Proton Therapy for Centrally Located Non-small Cell Lung Cancer.

BACKGROUND/AIM: To investigate the outcomes of patients with centrally located non-small-cell lung cancer (NSCLC) treated with proton beam therapy (PBT) using moderate hypofractionation. PATIENTS AND METHODS: Between 2006 and 2019, 34 patients with centrally located T1-T4N0M0 NSCLC who received moderate hypofractionated PBT were retrospectively reviewed. RESULTS: The median follow-up was 50.8 months (range=5.8-100.4 months). The 3-year overall survival, progression-free survival (PFS), and local control rates were 70.4%, 55.5% and 80.5%, respectively. Grade 2 or 3 lung adverse events (AEs) after PBT were observed in five (14.7%) patients; however, grade 3 radiation pneumonitis was observed in one (2.9%) patient. Notably, no grade 4 or higher AEs were observed. Regarding the correlation between the lung dose and proximal bronchial tree maximum dose and grade 2 or higher lung AEs, a weak correlation was observed between the mean lung dose and AEs (p=0.035). Although the clinical target volume (CTV) was a risk factor for poor PFS, no significant correlation was found between the CTV and lung AEs after PBT. CONCLUSION: Moderate hypofractionated PBT may be a useful radiotherapy method for centrally located cT1-T4N0M0 NSCLC.

Preliminary Study on Establishing a Heart Rate Variability-based Method for Objectively Evaluating Bone Metastasis Pain.

BACKGROUND/AIM: The aim of this study was to establish an objective evaluation method for pain due to bone metastasis, based on heart rate variability (HRV). PATIENTS AND METHODS: In this prospective study, patients who underwent radiotherapy for painful bone metastases were enrolled. Pain was assessed using a numerical rating scale (NRS), and anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS). Autonomic and physical activities were evaluated by measuring HRV using a wearable device. NRS, HADS, and R-R interval (RRI) values were obtained upon starting, completing, and 3-5 weeks after radiotherapy. RESULTS: Between July 2020 and July 2021, 11 patients were enrolled. The median average NRS score was 5 (range=2-10). HADS-assessed median anxiety and depression scores were 8 (range=1-13 and 2-21). For patients with an NRS score ≥4, NRS score was significantly associated with low-frequency/high-frequency (LF/HF) component ratio (p=0.03). Heart rate during physical activity was significantly higher than resting heart rate; however, mean resting LF/HF was significantly higher than LF/HF during physical activity. During rest, excluding patients with a HADS depression score ≥7 in an NRS score 1-3, there was a trend for a positive correlation between the NRS score and the mean LF/HF (p=0.07). CONCLUSION: HRV measurements can objectively evaluate pain due to bone metastasis. However, we must consider that the effects of mental status, such as depression, on LF/HF also affect HRV in patients with cancer with mild pain.

Proton Beam Therapy in Elderly Patients With cT1-3N0M0 Non-small Cell Lung Cancer.

BACKGROUND/AIM: To investigate the outcomes of elderly patients with cT1-3N0M0 non-small cell lung cancer (NSCLC) undergoing proton beam therapy (PBT). PATIENTS AND METHODS: Between 2009 and 2019, 110 patients receiving hypofractionated PBT for cT1-3N0M0 NSCLC were retrospectively reviewed. RESULTS: The median follow-up was 36.5 months (range=4.9-131.0 months). In the elderly group (80 years or older), the 3-year overall survival and progression-free survival rates were 79.8% and 73.9%, respectively, and the corresponding rates in the younger group were 80.5% and 61.2%, respectively. Grade 3 radiation pneumonitis (RP) was observed in 4.4% patients in the young group, whereas no grade 3 RP was observed in the elderly group. Age was not a risk factor for symptomatic RP. There were no significant differences in the survival and adverse events between the elderly and younger groups. CONCLUSION: PBT may be a reasonable approach for treating lung cancer in elderly patients with T1-3N0M0 NSCLC.

Efficacy of the pretreatment geriatric nutritional risk index for predicting severe adverse events in patients with head and neck cancer treated with chemoradiotherapy.

OBJECTIVE: The Geriatric Nutritional Risk Index (GNRI) is a simple and well-established nutritional assessment tool. Although concurrent chemoradiotherapy (CCRT), particularly cisplatin-based CCRT, is a standard treatment for locoregional advanced head and neck squamous cell carcinoma (HNSCC), the predictive factors of adverse events related to CCRT remain to be elucidated. The present study aimed to determine the association between GNRI and CCRT-related adverse events in patients of all ages with head and neck cancer (HNC) who underwent CCRT. METHODS: We retrospectively analyzed and compared the clinical characteristics and adverse events of 82 patients with HNC treated with CCRT according to their GNRI at the Department of Otolaryngology, Head and Neck Surgery, University of Tsukuba Hospital, between May 2014 and November 2019. The GNRI was calculated according to the equation: 1.489 × serum albumin (g/L) + 41.7 × (body weight/ideal body weight). We compared two groups: low GNRI (GNRI < 98) and normal GNRI (GNRI ≥ 98) groups. RESULTS: Eighty-two patients were enrolled in this study. There were 61 (76%) and 21 (26%) patients in the normal GNRI group and low GNRI group, respectively. There were significant differences in the incidence of grade ≥ 3 radiation mucositis, radiation dermatitis, and leukopenia between the low GNRI group and the normal GNRI groups. CONCLUSIONS: Patients with low GNRI scores were more likely to have severe adverse events. Pretreatment GNRI predicted severe CCRT-related adverse events in patients of all ages with HNC undergoing CCRT.

Hypofractionated Proton Beam Therapy for cT1-2N0M0 Non-small Cell Lung Cancer Patients With Interstitial Lung Disease.

BACKGROUND/AIM: To evaluate the outcomes of proton beam therapy (PBT) for early-stage non-small cell lung cancer (NSCLC) in patients with interstitial lung disease (ILD). PATIENTS AND METHODS: Between 2002 and 2017, 110 patients receiving hypofractionated PBT for cT1-2N0M0 NSCLC were reviewed. RESULTS: Of the 110 patients, 17 were diagnosed with ILD. The median follow-up period was 37.8 months. No significant difference in the 1-year cumulative rate of grade ≥2 pneumonitis was observed between patients with and those without ILD (17.6% vs. 14.1%, p=0.708). The lung doses were significantly lower in patients with than in those without ILD among patients without grade ≥2 pneumonitis. There were no significant differences in overall survival or local recurrence-free rates according to the presence of ILD. CONCLUSION: PBT appears to be a feasible and effective treatment for cT1-2N0M0 NSCLC in patients with ILD, but the lung dose should be strictly reduced.