Spotlight on Japanese physicians: An exploration of their professional experiences elicited by means of narrative facilitators.

BACKGROUND: While investigation of physicians' work experience is often limited to issues of satisfaction or burnout, a broader view of their experiences is lacking. OBJECTIVE: To explore professional experiences, we asked Japanese physicians (N = 18, 12 men and 6 women) of a general hospital to react to so-called "narrative facilitators". METHODS: The narrative facilitators - inspired by clinical psychology, visual sociology and purpose-designed techniques - oriented physicians' narratives towards clinical practise, relationship with peers and context. Transcribed interviews were subject to thematic analysis. RESULTS: The thematic analysis of participants' narratives revealed a lonely physician with a tough job, torn between the ideal of patient-centred care and a clinical reality, which limits these aspirations. Patients emerged as anxious and burdensome consumers of medicine. Feeling neither supported by peers nor the institution, physicians also perceived the society as somewhat negligent, delegating its problem to medicine. Communication difficulties, with patients and peers, and the absence of joyful aspects of the profession constituted fundamental elements of their narratives. CONCLUSIONS: Comprehensive investigation of physicians' lived professional experience could become a key to conceive ways to support them.

Progenitor cell numbers (CFU-GM, CFU-D, and CFU-Mix) and hemopoietic recovery following autologous marrow transplantation.

Forty-one consecutive patients were treated with high-dose chemotherapy with or without total body irradiation followed by autologous marrow transplantation. Four treatment regimens of varying intensity were used. Every patient's harvested marrow was evaluable for nucleated cell and progenitor cell loss during the cell separation and cryopreservation process. Of the 41 patients, 38 were evaluable for peripheral blood count recovery. Multivariate analysis of colony-forming cell assays and recovery of neutrophils and platelets showed a significant association with absolute numbers of post-thaw mixed colony-forming units (CFU-Mix) infused (p less than 0.002). Prefreeze CFU-Mix also correlated with recovery to a lesser degree, as did absolute numbers of nucleated cells. The number of diffusion chamber colony-forming units (CFU-D) prefreeze, but not post-thaw infused into the patient, was associated with recovery of neutrophils (p = 0.0001), but not platelets. When the precursor cell numbers were adjusted for body weight, post-thaw CFU-Mix showed the best correlation with recovery of both platelets and neutrophils. Prefreeze CFU-D per kg was also associated with recovery of neutrophils (p = 0.02). To some extent nucleated cells per kg predicted for recovery with neutrophils and platelets (p less than 0.05). When analyzed according to treatment regimen, cyclophosphamide-BCNU-VP16 (CBV) or cyclophosphamide-total body irradiation (CY/TBI) was associated with prolonged recovery compared to cyclophosphamide-adriamycin-vinblastine (CAV) or etoposide-cyclophosphamide (EC). In this setting only CFU-D number predicted neutrophil recovery (p less than 0.002). We conclude that determination of the number of total nucleated cells, CFU-D, and CFU-Mix, before cryopreservation of the sample is important in predicting hemopoietic reconstitution in autologous bone marrow transplantation.

Influence of arachidonate metabolism on enhancement of intracellular transglutaminase activity in mouse peritoneal macrophages.

We examined whether arachidonate metabolism exerted any influence on the enhancement of intracellular transglutaminase activity in mouse peritoneal macrophages. Enhancement of the intracellular transglutaminase activity was observed on stimulation of macrophages with normal sheep red blood cells (SRBC) or immunoglobulin G (IgG)-coated SRBC, and was inhibited by inhibitors of phospholipase A2 and cyclooxygenase. Moreover, prostaglandin E2 (PGE2), a main product of the cyclooxygenase pathway, leukotriene B4 (LTB4), a product of 5-lipoxygenase, and arachidonic acid also could directly induce high levels of intracellular transglutaminase activity without stimulation of macrophages by SRBC or IgG-coated SRBC, but leukotriene C4, prostaglandin D2, and prostacyclin were unable to induce high activity of the enzyme. Enhancement of transglutaminase activity induced by LTB4 was inhibited by cyclooxygenase inhibitor, but the enzyme activity induce by PGE2 was not inhibited. Furthermore, the quantity of PGE2 released into the culture medium of macrophages stimulated with SRBC or IgG-coated SRBC correlated well with the activity of intracellular transglutaminase in macrophages. Moreover, enhancement of transglutaminase activity by treatment of macrophages with SRBC or IgG-coated SRBC was partially suppressed by sodium benzoate, which is a scavenger of hydroxy radical. These findings suggest that arachidonate metabolism, in particular the cyclooxygenase pathway, plays an important role in the enhancement of intracellular transglutaminase activity.

Induction of platelet-activating factor in mice by intravenous administration of a neutral fraction of bakers' yeast mannan.

A neutral subfraction of mannan of bakers' yeast (WNM) was found to show a lethal effect in mice when administered intravenously. Symptoms caused by intravenous (i.v.) administration of WNM resembled those resulting from the administration of platelet-activating factor (PAF). CV-3988 and ONO-6240, selective PAF antagonists, prevented hypotension and death caused by the administration of WNM or PAF. A beta-adrenoceptor agonist was shown to prevent death caused by WNM, whereas propranolol increased the lethal activity of WNM. Intravenous administration of WNM into mice produced PAF in gall bladder fluid which was determined by platelet aggregation assay. The findings indicate that WNM is able to induce PAF in mice and that the resultant PAF may participate in the WNM-induced lethal activity observed in mice.

Successful treatment of a case of relapsed acute promyelocytic leukemia with arsenic trioxide.

We report a patient with an initial relapse of acute promyelocytic leukemia (APL) who achieved a second complete remission (CR) after treatment with arsenic trioxide. The patient, a 66-year-old woman diagnosed as having relapsed APL, received arsenic trioxide intravenously at a dose of 10 mg/day. At day 36, the patient achieved a second CR. The side effects were slight neuralgia and mild skin erythematous changes, which improved following cessation of the drug. Although arsenic trioxide may be effective for relapsed APL, it should be used with caution because of various complications.

Calcium absorption from the ingestion of coral-derived calcium by humans.

Recent dietary life involves frequent opportunities for the ingestion of purified, processed food products and preserved foods, and it has been pointed out that the current dietary mineral intake strongly tends toward nutritional imbalance. The Ryukyu Islands yield coral which contains calcium and magnesium in a content ratio of about 2 to 1, with their approximate contents of 20 and 10%, respectively. In this report, the calcium absorption from the ingestion of crackers into which the coral powder was incorporated (coral-added crackers) and that from ingestion of calcium carbonate-added crackers was comparatively assessed. Twelve healthy adult volunteers (6 men and 6 women) ingested coral-added crackers (calcium content: 525 mg) and calcium carbonate-added crackers (ditto) once each alternately on a cross-over design with a wash-out period of 3 d between the regimens. The study also included controls receiving neither cracker. The degree of intestinal absorption of calcium from coral-added crackers and that from calcium carbonate-added crackers was evaluated in terms of increment in urinary calcium excretion per dL of glomerular filtrate (GF) (difference between coral calcium and calcium carbonate) and increase in urinary calcium excretion per milligram creatinine (difference from control value). The increment in urinary calcium excretion per dL of GF during the latter half of the observation period after the ingestion of coral-added crackers was significantly greater than that during the latter half of the observation period after ingestion of calcium carbonate-added crackers (p = 0.039, paired t-test). A significant difference (from control value) in the increase of urinary calcium excretion per milligram creatinine was also observed (p = 0.0008). The present data, though from a relatively few study subjects, suggest that the calcium of coral origin is better absorbed from the intestine than calcium of calcium carbonate origin on the average.

[The present situation and problems of home care for advanced cancer patients].

An attempt to introduce home care for advanced cancer patients has started throughout Japan. However, there are many problems which prevent its development into an established medical care system. We conducted a nationwide survey on the current situation surrounding home care for advanced cancer patients. We selected 20 hospitals around the country and examined 268 cases. The categories surveyed were: type of cancer; medical care system; medical treatment; informed consent; and the patient's death at home. The result shows that cancer of the colon, stomach, breast and lungs are the most prevalent forms of cancer. In some cases the team approach organized mainly by doctors and nurses was introduced, though to limited extent. The most common forms of treatment were chemotherapy, pain management and nutrition control. At the same time, many hospitals tried to establish a system which focuses on QOL. Informed consent was obtained in 60% of the cases and 10% of the patients died at home. According to our survey, a medical care system incorporating traditional home care (hospice home care) and high-technology home care is being pursued in Japan. The insufficiency of the home care system and the lack of education leading to qualification for clinical oncologists and oncology nurses are the most significant problems.

[Progress in palliative medicine].

The major factors in the progress in palliative medicine in Japan are the hospice movement, as represented by the activities of the Japanese Association for Clinical Research on Death and Dying, and interdisciplinary research on the quality of life (QOL), particularly in the field of clinical oncology. Palliative medicine as a new paradigm today encompasses the fields of biology, psychology, sociology, and ethics, all of which are making steady progress under the banner of evidence-based medicine. In recent years, the problems of euthanasia and physician-assisted suicide, subjects of great debate and public concern, especially in America and European countries, have been studied in the field of psycho-oncology and continue to attract considerable attention. The relationship between depression and social supports is said to be of particular importance. The American Society of Clinical Oncology (ASCO) has made a positive statement to the effect that it would not hesitate in confronting the so-called "end-of-life" issue. All of these global trends point to the increasing importance of palliative medicine.

[Multiple plasma exchanges in patients with advanced malignant disease].

Multiple plasma exchange represents an empirical attempt to clear "immunosuppressive factors" from the plasma of cancer patients. Plasma exchanges have been performed in 32 patients with advanced malignant disease. Up to 4000 ml of plasma have been replaced by one single plasma exchange. Serum proteins including acute phase reactants were monitored before and after plasma exchange. A transient change of these proteins was observed on the first day, but later on, pretreatment values were always regained. Skin reactions to recall and new antigens were enhanced in many patients after plasma exchanges. Peripheral blood lymphocyte blastogenic response to mitogen was slightly increased in patients after plasma exchanges. Plasma exchange was found to decrease significantly the inhibitory effect of patients' sera on normal donor lymphocyte reactivity. Therefore, multiple plasma exchanges could have a practical role to play in immunotherapy.

[Quality of life for older people under oncological treatment].

Recently, an argument over the medical treatment of older patients has arisen in the field of clinical oncology. In the past oncological treatment has been geared to young and middle-aged people. Currently, oncological treatment takes the peculiarities of older people into consideration. Firstly, it highlights the multidimensionality of Quality of Life (QOL) as an important element, with subjectivity the second element. This notion has gained a worldwide consensus. The domain of "multidimensionality" consists of: 1. Physical status and functional abilities 2. Psychological status and well-being 3. Social interaction 4. Economic status and factors With these factors in mind, different questions are asked, depending on the condition of each patient, in order to let the patient form his/her own judgment on possible medical treatment. However, it is sometimes difficult for older people to make such judgments due to problems such as depression or their diminishing mental ability. Also, it is impossible to define life satisfaction indiscriminately without regard to individual outlook. QOL for older people is generally characterized by "individuality" which includes: 1) A person's integrity; 2) independence; and 3) autonomy. Though these elements are taken into account in adopting the above-mentioned methodology, the field of clinical oncology's two concepts of QOL still apply in principle. Flexibility to put emphasis on different elements of the domain will be necessary. Even though QOL for older people is a matter of subjective judgment, the "sound judgment of professionals" (objective and scientific judgment of caregivers) can be adopted in cases when there is difficulty in communication.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of advanced ovarian clear cell adenocarcinoma responding to cisplatin-cyclophosphamide and paclitaxel-carboplatin].

We report a case of stage IV ovarian clear cell adenocarcinoma successfully controlled by a combination of cisplatin-cyclophosphamide (CP) and paclitaxel-carboplatin (TJ). A 64-year-old female with advanced ovarian cancer and pleural effusion underwent 4 courses of combination chemotherapy with CP. The giant ovarian tumor showed a relative reduction in size and the pleural effusion disappeared. Serum CA-125 levels and CA 19-9 levels markedly decreased. Thus, the patient underwent a total hysterectomy and bilateral salphingoophorectomy. During the operation, a giant ovarian clear cell adenocarcinoma was found, but there was no peritoneal dissemination and no cancer cells in her peritoneal fluid. Thereafter, she underwent 3 courses of combination chemotherapy with TJ. She has had 13 months of stable, tumor-free survival since the operation and normal serum CA-125 and CA 19-9 levels. Ovarian clear cell adenocarcinoma generally responds poorly to cisplatin and carboplatin, but in combination chemotherapy with paclitaxel-carboplatin these may be effective.

[Analysis of human sera obtained from lung cancer patients by two-dimensional electrophoresis after schizophyllan (SPG) treatment].

Schizophyllan (SPG) was administered to 13 lung cancer patients (i.m. 20mg X 2/week) for 3 weeks without chemo or irradiation therapies, and serum proteins were analyzed by two-dimensional electrophoresis (TDE). Additionally, immunosuppressive acidic protein (IAP) was quantitatively determined by single radial immunodiffusion (SRID). By TDE analysis, human serum proteins were separated into more than 100 spots, and about 14 spots were found to show quantitative changes in cancer patients. Quantitative examination was therefore conducted on changes of 8 components among these spots, including alpha 1-acidic glycoprotein (alpha 1 AG), acidic alpha 2-macroglobulin (acidic alpha 2 M), haptoglobin (Hp) and IAP. The protein which showed the most marked decrease in cancer patients, located between transferrin and IgG on the above TDE patterns, was ascertained to have a molecular weight of about 150,000 using a gel filtration method. This protein was increased in 7 of 13 patients after SPG treatment.

[Importance of oral and dental care in home medical care].

Recently, the importance of home medical care has been stressed. But patients, those assisting them and home care nurses do not attach much importance to oral and dental care in home medical care. When we visit patients who have asked for dental treatment through home care nurses, they appeared to have very poor oral hygiene; cavities were uncared for, dental plaque and dental calculus built up, and they used ill-fitting dentures. Through home dental care visits, it was not just the dental treatment but advice on dental hygiene management and diet that helped patients regain their appetite and bring back a smile to their face, while giving a rhythm to their life. This created a certain human feeling and brought about better patient quality of life (QOL), while at the same time helping to improve the QOL of the family as well.

[Clinical phase II study of 5'-DFUR for cancer of the digestive organs by a cooperative study group].

Phase II study of a new 5-fluorouracil derivative, 5'-deoxy-5-fluorouridine (5'-DFUR), was performed with oral administration. Forty-nine patients with advanced cancer of the digestive organs, lung and breast were entered, and 8 institutions in Hokkaido were involved. 5'-DFUR was administered three or four times a day at a daily dosage of 600 to 1200 mg. Partial response was observed in three gastric cancer cases and two breast cancer cases out of 39 evaluable cases, and minor response was observed in one colorectal cancer case. Overall response rate was 12.8%, 15.8% in gastric cancer and 66.7% in breast cancer. Side effects were observed in 15 cases out of 45 (33.3%), which mainly consisted of gastro-intestinal disturbances such as diarrhea.

[Phase I clinical trial of RP 56976 (docetaxel) a new anticancer drug].

A multicenter phase I clinical trial of RP 56976 (docetaxel), a new anticancer drug, was performed with single and repeated doses. Based on the results of phase I clinical trials conducted in the United States and Europe, the starting dose was 10 mg/m2. The dose was subsequently increased to 20, 50, 70 and 90 mg/m2. A dose of 60 mg/m2 was additionally tested. Single administrations of the six dose levels were performed in a total of 27 patients via intravenous drip infusion over one hour. Ten of the patients subsequently received repeated doses at three of the dose levels in the same manner. The dose limiting factor (DLF) of docetaxel is leukopenia (especially, neutropenia). Based on the observation of the DLF, the maximum tolerated dose (MTD) was determined to be 70-90 mg/m2. The white blood cell count reached a nadir about 9.5-19.5 days (median) after administration, and took 7-11 days (median) to recover. Other adverse reactions observed were nausea/vomiting anorexia, alopecia, diarrhea, fatigue and fever, which were all acceptable. The results of this trial suggest that a dosage regimen of 60 mg/m2 at 3- to 4 week intervals is appropriate in an early phase II clinical trial.

[Antitumor and anticachectic activity of UFT in BALB/c mice bearing colon 26 adenocarcinoma].

We established a cancer cachexia model in BALB/c mice bearing Colon 26 and examined antitumor and anticachectic activity of UFT. The mice bearing Colon 26 showed a progressive loss of body weight, loss of lipid, and hypalbuminosis associated with the change of tumor size and these symptoms were improved by removal of cancer. In this model UFT extended life span significantly at 15mg/kg/day though showed a little growth inhibitory activity. UFT showed a significant tumor growth inhibitory activity and extended life span at 20mg/kg/day and could reverse all biological parameters mentioned above. Since the intratumor and plasma contents of IL-6 were significantly lowered in the UFT administered group, it is estimated that the anticachectic activity of UFT originates from reduction of interleukin-6 in tumor.