[Considering the Role of Home Care Support Clinics at a Pre-Discharge Conference].

In this study, we considered the role of home care support clinics for patients who wanted to go back to their homes from a hospice, duringa pre-discharge conference. The subjects of our study were 8 patients, of which 7 of them had cancer. Two patients died after the conference. These patients were discharged from the hospice three days after the conference and caregivers from the home care support clinics visited their homes 24 hours after their discharge. The clinic has a role to fulfill in terms of medical treatment and support, based on their life style and power of caregiving. We considered an advancedmeetingwith family or caregiver benefits in the conference. Further, the clinic has a role of establishinga relationship with each multi-disciplinary care unit and cooperate with them as soon as possible when needed.

[Usefulness of Peripherally Inserted Central Venous Catheters for Cancer Patients in Palliative Care Settings].

Peripherally inserted central venous catheters(PICCs)are widely used given they have lower incidence of serious complications than central venous catheters. We evaluated the safety and usefulness of ultrasound-guided PICC placement for cancer patients in palliative care settings. We attempted to insert PICCs in 42 patients, and the insertion was successful in 40 (95.2%)patients. Complications occurred in 9(22.5%)patients, but none were severe. In 30 cases, PICCs were used for infusion and drug delivery until cancer death. The duration of catheterization was 25(1-126)days. Our results suggest that ultrasound-guided PICC represents a safe and usefultoolfor cancer patients in palliative care settings.

[Aiming at the Spread of Palliative Care in Community Health Care-Consideration of Human Resource Development from the Viewpoint of the Home Physician and Support Hospital].

Palliative care for cancer patients requires information sharing, including prognoses, to fulfill the wishes of the patient and patient's family as well as to avoid wasting time. It is necessary to recognize the importance of the pre-discharge conference and home medical care to realize the wishes of the patient and the patient's family.

[Influence of the Timing of Cessation of or Withholding Chemotherapy and End-of-Life Care at Home in Patients with Incurable Solid Cancers-An Interim Report of the Results of the Questionnaire Survey among Home Care Physicians in Japan].

BACKGROUND: The study analyzed data obtained using a questionnaire on the potential discriminative characteristics of patients with an incurable solidcancer who receivedor didnot receive palliative chemotherapy during end-of-life care at home. From the standpoint of regional palliative care, we aimed to investigate the influence of the timing of cessation of or withholding chemotherapy andend -of-life care at home in patients with incurable solidcancers. We plannedthe project to obtain scientific evidence about the timing of cessation of or withholding chemotherapy. METHODS: The study included all patients with solidcancers treatedwith or without palliative chemotherapy who diedat home in 2016 in Japan. We distributed postcards of the invitation to participate in the questionnaire survey to more than 2000 home care physicians in Japan. The questionnaires administeredto home care physicians were registeredin website surveys from May to November 2017. The questionnaire data were analyzed using nonparametric methods. RESULTS: We previously obtained information from 576 patients at 170 medical facilities from May to August 2017. As we continue the study, we release an interim report of the questionnaire survey among home care physicians. Of the patients, from the time of diagnosis of the incurable solid cancer, 40% hadreceivedchemotherapy and6 0% hadnot. CONCLUSION: The 60% of patients who didnot undergo chemotherapy since diagnosis were a problem to our projects. However, as we continue the questionnaire survey, we would like to analyze the data from the returned questionnaires.

[End-of-Life Decision Making Support in Palliative Homecare].

Advance care planning is important in end-of-life decision making in home-based palliative care for both cancer patients and non-cancer patients.

[The Influence of the Timing of Ceasing or Withholding Chemotherapy in Home-Based End-of-Life Care in Patients with Incurable Solid Cancer - Release of an Interim Report of the Questionnaire Survey to Home Care Doctors in Japan].

BACKGROUND: The study analyzes a questionnaire on the potential discriminative characteristics of patients with incurable solidcancer, who either receivedor didnot receive palliative chemotherapy while receiving home-basedend -of-life care. From the standpoint of regional palliative care, we sought to investigate the influence of the timing of when chemotherapy was ceasedor withheldin home-basedend -of-life care in patients with incurable solidcancer. We plannedthe project to obtain scientific evidence about the timing of ceasing or withholding chemotherapy. PATIENTS AND METHODS: The study includes all patients with solidcancer treatedwith or without palliative chemotherapy andwho diedat home in 2016 in Japan. We delivereda postcardof invitation to participate in the questionnaire to more than 2,000 home care doctors in Japan. The questionnaires were registeredas online surveys from May to November 2017. The questionnaire data were analyzed using nonparametric methods. RESULTS: We obtained information from 576 patients at 170 medical facilities from May to August 2017, but the study is currently ongoing; hence, we have released an interim report of the questionnaire results. Among the patients, 40%receivedchemotherapy and 60%didnot since the time of the first incurable solidcancer diagnosis. CONCLUSION: The majority 60% of patients not receiving chemotherapy was a setback to our project. However, as the questionnaire survey continues, we wouldlike to analyze these data after collecting more results.

[Clinical Utility of Tapentadol].

Tapentadol(TP)is a new strong opioid analgesicthat has both m-opioid receptor(MOR)effects and norepinephrine reuptake inhibitor(NRI)effects. In comparison with the existing strong opioid analgesics, the mechanism of action suitable for palliation of neuropathic pain is expected to be better for TP. The analgesic effect and side effects of this drug were tested in 10 cases of exacerbation of neuropathic pain at our hospital, and the sedative response rate was 70%. The main side effects were somnolence 44.4%, nausea 33.4%, and constipation 11.1%. The side effects on the digestive system were considered minimal. Although it is speculated that opioids would be useful as an outpatient treatment, few case reports are available regarding their use for cancer pain; therefore, further investigation is necessary. Generally, numerous social issues that would increase the likelihood of drug adherence failure must be addressed in order to expand the use of strong opioid analgesics such as TP. Both the patients and the healthcare worker should be involved when addressing these issues in Japan, and the measures should include instructions for appropriate reporting and for using such drugs.

[Cell-free and concentrated ascites reinfusion therapy(CART)].

The cell-free and concentrated ascites reinfusion therapy(CART)is a useful palliative maneuver in a patient suffering from ascites. I think that home medical care cooperation is essential to diffuse at home CART.

[A case of stage IV b pancreatic cancer in which a catheter-related infection caused by epidural/subcutaneous reservoir therapy affected palliative home-based care].

We report the case of a patient with a stage IV b pancreatic cancer in which epidural/subcutaneous reservoir therapy was effective for pain control. However, a catheter-related infection caused by methicillin-resistant Staphylococcus aureus (MRSA)was occurred. In recent years, the number of cancer patients desiring palliative home-based care in Japan has increased. Epidural/subcutaneous reservoir therapy is often offered to relieve refractory pain, and to reduce the side effects of systemic administration of opioids, such as drowsiness, in homecare patients. We believe that this patient may have been able to continue home-based care if the catheter-related infection did not occur, because a significant improvement was calculated in the pain level by the numerical rating scale(NRS)observed. It is important to establish and share common strict guidelines between hospital doctors and general practitioners for the management of the subcutaneous catheter and reservoir therapy in order to prevent catheter-related infections over a long period.

Novel cell-free and concentrated ascites reinfusion therapy (KM-CART) for refractory ascites associated with cancerous peritonitis: its effect and future perspectives.

BACKGROUND: We have actively carried out cell-free and concentrated ascites reinfusion therapy (CART) for refractory ascites. However, with conventional CART, the membrane becomes clogged after processing about 2 L of cancerous ascites fluid due to the fact that it is rich in cellular and mucous components; it is therefore difficult to process the entire volume of collected ascites. METHODS: We developed KM-CART which includes a membrane cleaning function, and applied it in 73 cases of cancerous ascites, after its basic functions had been evaluated in 11 cases of refractory cancerous ascites. RESULTS: On average, using KM-CART, 6.4 L (range 1.7-14.9 L) of ascites were filtrated and concentrated to 0.8 L (0.2-2.0 L) in 57 min (5-129 min); the membrane was cleaned an average of three times (range 0-10 times) and this enabled the processing of more ascites in a shorter period. In addition, the circuit and the handling were both markedly simple, and fever, which has been the most notable adverse effect with the conventional system, was not an issue. CONCLUSION: Since KM-CART was safe and is expected to improve the subjective symptoms and general condition of the patient, it is proposed that this novel system should actively be used not only for palliation but also as supplementary treatment for cancerous peritonitis.

[The change in home palliative care].

A promotion of home palliative care at our clinic has been built with many factors including a home medical care desired by patient's family, governance of the law, progress of medical measures and an improvement of medical cooperation.

[Is home palliative care for head and neck cancer patients a possibility ?].

It is likely that home palliative care for head and neck cancer patients could be treatable at general hospitals or clinics whereas combined joint efforts by medical cooperation from specialists, who are specialized in understanding of the singularity and how to cope with the symptoms, are existed.

[Usefulness of epidural catheter with the subcutaneous reservoir for cancer pain control in homecare service].

The epidural block therapy is offered to reduce one of the side effects of systemic administration of opioids such as drowsiness. Hence, it is necessary to set a subcutaneous reservoir to prevent a catheter-related infection for a long period of time. One hundred twenty five patients with this manipulation during the year 2004 to 2010 showed a significant improvement in their pain level calculated by Numerical Rating Scale(NRS). However only 30 cases could be proceed to the homecare. There was one case of catheter-related infection in 30 homecare cases. It is useful to establish the common strict guidelines between hospital doctors and general practitioners for the management of the epidural catheter with subcutaneous reservoir.

Development of a predicting tool for survival of terminally ill cancer patients.

OBJECTIVE: To develop a predicting tool for survival of terminally ill cancer patients. METHODS: This prospective, multicenter study was composed of two cohorts of samples: development and test. In the development sample of terminally ill cancer patients, 32 candidate predictors were studied to develop a new tool, Japan Palliative Oncology Study-Prognostic Index using the Cox proportional hazard model. Then the test sample was studied to validate Japan Palliative Oncology Study-Prognostic Index and compared it with the conventional predicting tools, such as palliative prognostic score and simplified palliative prognostic index. RESULTS: Five significant predictors, physician's clinical prediction of survival, consciousness, pleural effusion, white blood cell count and lymphocyte % were derived from the analysis of 201 patients, and Japan Palliative Oncology Study-Prognostic Index was developed using these predictors. It could divide patients into three risk groups: low (A), intermediate (B) and high (C). Median survival times for Groups A, B and C were 51, 35 and 16 days, respectively. Survival probability for more than 30 days for Groups A, B and C in the development sample was 78%, 61% and 16%, respectively. Japan Palliative Oncology Study-Prognostic Index was studied in subsequent 208 patients for the test sample, and constant results (median survival times for Groups A, B and C; 67, 31 and 10 days, and survival probability for more than 30 days for Groups A, B and C; 81, 48 and 11%) were obtained. Palliative prognostic score can also predict three risk groups well, but simplified palliative prognostic index could not discriminate low risk from intermediate risk group. CONCLUSION: Japan Palliative Oncology Study-Prognostic Index, a tool to predict survival, has been developed. Its reliability should be confirmed further in the future study, comparing with palliative prognostic score.

[Experimental inhalation therapy with nebulized tiotropium in COPD patients unable to use the Handihaler].

BACKGROUND: We report the efficacy and safety of experimentally nebulized tiotropium use. We identified 19 elderly very severe COPD (GOLD stage IV) inpatients unable to use tiotropium in the Handihaler by themselves from January 2008 through May 2009. The contents of an 18 microg capsule of tiotropium were dissolved in 5 ml saline and nebulized via a nebulizer. RESULTS: Nebulized tiotropium improved the symptoms of all COPD patients, and the ADL scores of 12 COPD patients. All COPD patients tolerated nebulized tiotropium well, although mild dry mouth was reported by a single COPD patient. CONCLUSION: Tiotropium therapy for COPD patients is recommended in all GOLD stages. Our report showed that COPD patients (GOLD stage IV) who had difficulties using a tiotropium Handihaler benefitted from nebulized tiotropium. This helped them to continue their COPD therapy and was demonstrated to be an effective and well tolerated treatment option.

[A case with an ovarian cancer patient who could receive anti-cancer therapy and palliative care simultaneously at home through seamless collaboration in healthcare linkage].

A palliative care team provides palliative care in the hospital setting.However, palliative care might be discontinued when a patient was switched to an outpatient from an inpatient or when a patient was being transferred to another hospital.In the present work, we report a case who could receive anti-cancer therapy and palliative care simultaneously at home.The case is a 46-year-old woman.She was diagnosed as left ovary cancer in 1990's and underwent an operation followed by chemotherapy. The tumor relapsed and invaded the sigmoid colon in 2000's.She then developed an intestinal obstruction and was hospitalized.After her conditions were stabilized, she was discharged but still needed a high degree of medical interventions. She was introduced to another hospital providing a home palliative care as well as emergency admission.She could fulfill her desire to receive a palliative care and chemotherapy simultaneously at home through this seamless healthcare linkage.It should be insisted that hospital oncologists and home doctors need to acquire the knowledge of palliative care and close cooperation between them is required.It is also important to establish a comprehensive healthcare linkage system in the society.

[BNP measurement for perioperative management].

BACKGROUND: It is difficult to evaluate the tolerance to anesthesia of patients undergoing operations, who have risk factors of congestive heart failure, such as hypertension, old age or various cardiac diseases. BNP (B type natriuretic peptide) is a useful biomarker as a screening tool for LV dysfunction. Therefore we hypothesized that the measurement of BNP may be useful for perioperative management of these patients. METHODS: Subjects were 101 (58 male and 43 female) gastro-intestinal cancer patients, aged 30 to 91 years (mean 63.9 +/- 12.4) scheduled for intraperitoneal surgery. All patients' plasma BNP concentrations were measured when the patient agreed to the operation. Forty-five patients were enlisted for remeasurements on 2 or 4 postoperative days. We checked patients' backgrounds, perioperative circulatory characteristics and cardiac events. The relationship of BNP to other characteristics and cardiac events were analyzed. RESULTS: The preoperative mean BNP of patients under 55 years of age (n=20) was 20.4, in patients age 55 to 74 (n=60) it was 30.4, and in patients 75 years and over (n=21) it was 162.1. BNP in elderly patients was higher than in the younger. The mean BNP of the 44 patients with some complications (hypertension, ECG abnormality, cardiac disease etc.) was 97.8, as compared to 23.3 in the 57 patients without complications. The BNP was higher in patients who were elderly, had some cardiac disease, lower exercise capacity, chest X ray abnormality or who needed an echo cardiographic examination. Among the 45 patients who were checked pre and postoperatively, 19 patients' BNP increased postoperatively, while 26 patients showed no change or decrease. Excluding 2 patients, with newly onset congestive heart failure during the postoperative period, the preoperative mean BNP was 63.5, and the postoperative mean BNP was 54.6. During the perioperative period, there was no significant change of BNP. There was no relationship between the BNP and perioperative circulatory characteristics or cardiac events. There were 5 cases with high BNP levels (> 300). None of these patients had cardiac symptoms, and they had normal LV systolic function. It is probable that these patients had chronic heart failure due to LV diastolic dysfunction and risks of perioperative heart failure. CONCLUSIONS: We cannot predict any circulatory characteristics and cardiac events from preoperative BNP measurement; however BNP measurement is useful for screening asymptomatic chronic heart failure due to LV diastolic dysfunction.

[The medical cooperation in home palliative care--a design of cooperation with the visiting nursing station].

In home palliative care on site, the trinity of cooperation in "medical-nursing-patient" care is essential. It is necessary to cooperate with the visiting nursing station and to give special considerations in the areas of sharing information, understanding of the difference between in-patient and out-patient and the management of mental health of the caregivers.

[The medical cooperation in home palliative care with regard to "hospital-medical office and hospital-hospital disease cooperation"].

In the medical cooperation of home palliative care, it often happens to be one-way cooperation. Therefore, it is necessary to have a capability of "home medical support hospital" with functions like helping the patient and his family to prepare for a home care transition and a way to cope with emergency situations.

Artificial hydration therapy, laboratory findings, and fluid balance in terminally ill patients with abdominal malignancies.

To explore the association between hydration volume and laboratory findings, and between calculated fluid balance and changes in clinical signs of dehydration and fluid retention in terminally ill cancer patients, a secondary analysis of a large multicenter, prospective, observational study was performed. The study enrolled 125 abdominal cancer patients who received laboratory examinations in the last week before death. Patients were classified into two groups: the hydration group (n = 44), who received 1L or more of artificial hydration per day both 1 and 3 weeks before death, and the nonhydration group (n = 81). The mean albumin level 1 week before death was significantly lower in the hydration group than in the nonhydration group, and the interaction between hydration group and decrease in the albumin level was statistically significant after adjusting multiple covariates (from 2.8 +/- 0.68 mg/dL 3 weeks before death to 2.4 +/- 0.56 mg/dL 24 hours before death in the hydration group vs. a decrease of 2.8 +/- 0.53 to 2.6+ /- 0.45 mg/dL in the nonhydration group, P = 0.015). There was no significant difference between the groups in the mean blood urea nitrogen/creatinine, sodium, or potassium levels 1 week before death. Among 53 patients who had oral fluid intake of less than 500 mL/day throughout the last 3 weeks and completed a fluid balance study, the median of calculated fluid balance was -400 mL/day 3 weeks before death, -521 mL/day 1 week before death, and -421 mL/day 24 hours before death. Calculated fluid balances did not significantly differ between the patients with deterioration of dehydration signs, edema, ascites, and pleural effusion during the final 3 weeks and those without. These data suggest that active artificial hydration might result in hypoalbuminemia, with no clear beneficial effects on normalizing blood urea nitrogen/creatinine, sodium, or potassium levels. Fluid balance did not significantly correlate with changes in dehydration-and fluid retention-signs. Calculated fluid balance is not an appropriate alternative to direct monitoring of patient symptoms. More studies are needed to determine the clinical efficacy of artificial hydration for terminally ill cancer patients.