Publications by authors named "Jun Hamano"

51 Publications

Does Urinary Catheterization Affect the Quality of Death in Patients with Advanced Cancer? A Secondary Analysis of Multicenter Prospective Cohort Study.

J Palliat Med 2021 Oct 11. Epub 2021 Oct 11.

Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan.

Patients with life-limiting illnesses frequently experience urinary difficulties, and urinary catheterization is one of the interventions for managing them. However, evidence supporting the effects of urinary catheters on the quality of death (QoD) is lacking in this population. To investigate whether urinary catheterization affects QoD in patients with advanced cancer in palliative care units. A secondary analysis of a multicenter, prospective cohort study. The study enrolled consecutive patients with advanced cancer admitted to palliative care units in Japan between January and December 2017. Those who were not catheterized on admission and who died while in a palliative care unit were analyzed. QoD was evaluated at death using the Good Death Scale (GDS). Of 885 patients, 297 (33.6%) were catheterized during their palliative care unit stay. Females and patients with a long palliative care unit stay were more likely to be catheterized. In inverse probability-weighted propensity score analysis, patients with urinary catheterization during their palliative care unit stay had higher total GDS scores than those without catheterization (coefficient 0.410, 95% confidence interval 0.068-0.752). In subgroup analyses stratified by sex, age, and length of palliative care unit stay, urinary catheterization was associated with higher total GDS scores in patients younger than 65 years of age and those who died after a palliative care unit stay of 21 days or fewer. This study suggested that urinary catheterization during a palliative care unit stay may have a positive impact on overall QoD in patients with advanced cancer. This study was registered in the UMIN Clinical Trials Registry (UMIN000025457).
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http://dx.doi.org/10.1089/jpm.2021.0178DOI Listing
October 2021

Are family relationships associated with family conflict in advanced cancer patients?

Psychooncology 2021 Aug 28. Epub 2021 Aug 28.

Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan.

Objectives: Family conflict during end-of-life care is an important issue for advanced cancer patients and their families, although studies are lacking. We investigated the association between family relationships and family conflict in advanced cancer patients.

Methods: This study was a secondary analysis of a nationwide multicenter questionnaire survey targeting the bereaved family members of cancer patients who died in palliative care units, general wards, or at home to evaluate the quality of end-of-life care in Japan.

Results: A total of 1084 questionnaires (63.0%) were returned and we analyzed a total of 908 responses. In total, 38.0% of family members reported at least one family conflict during end-of-life care, and the most frequent family conflict was "about certain family members not pulling their weight" (23.5%). Multivariate linear analysis revealed family members who asserted their opinions (p < 0.001), family assessment device score (p < 0.001), worries about family finances during cancer treatment (p < 0.001), family members contacted after illness were helpful (p = 0.003), female patients (p = 0.03), and family with family relationship index ≤7 (p = 0.04) were positively associated with the outcome-family conflict (OFC) score. Proxy decision maker was selected by the patient (p = 0.003), people listened to families' worries or problems (p = 0.003), physician gave sufficient explanation (p = 0.003), living will before their illness (p = 0.038) and female bereaved family members (p = 0.046) were negatively associated with the OFC score.

Conclusions: It may be important for health care providers to actively assess the possibility of family conflicts according to family relationships, such as a proxy decision maker having been selected by the patient.
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http://dx.doi.org/10.1002/pon.5801DOI Listing
August 2021

Development of a Scoring System to Determine Proportional Appropriateness of Continuous Deep Sedation: A Concept-of-Proof Study.

J Palliat Med 2021 09 22;24(10):1539-1544. Epub 2021 Jul 22.

Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan.

Some patients require continuous deep sedation (CDS) for refractory symptoms despite intensive palliative care. The principle of proportionality is proposed on the basis of clinical decisions, but no validated tools to assist such decision making are available. To develop a scoring system to determine whether CDS is proportionally appropriate. A secondary analysis of a nationwide questionnaire survey of Japanese palliative care specialists was performed. Physicians were asked to rate the degree that they believed CDS to be appropriate in a total of 27 scenarios based on a combination of 3 factors with 3 levels: (1) the estimated survival (days, weeks, and months), (2) the patient's wish (clear and consistent, somewhat unclear and/or inconsistent, and unclear or inconsistent), and (3) confidence in refractoriness of the symptom (definite, probable, and unsure). Based on logistic regression analyses, a scoring system with two formulas (the proportionality score to determine that continuous deep sedation is appropriate [ProScoreCDS-appropriate] and proportionality score to determine that continuous deep sedation is inappropriate [ProScoreCDS-inappropriate]) to predict specialists' decision that CDS is appropriate or inappropriate was developed. The accuracy of the formulas was investigated. Among 695 palliative care specialists, 469 returned the questionnaire (response rate, 69%) and 440 were analyzed. Logistic regression analyses identified that all three factors were significantly associated with physicians' decisions about the appropriateness of performing CDS. Using weighted value, the total score ranged from 3 to 67 for ProScoreCDS-appropriate, and 3 to 27 for ProScoreCDS-inappropriate. The area under the curve (AUC) values of ProScoreCDS-appropriate and ProScoreCDS-inappropriate were 0.88 (95% confidence interval [CI], 0.87-0.89) and 0.81 (95% CI, 0.81-0.82), respectively. Using cutoff points of 41 and 14, sensitivity and specificity were 68.6% and 88.9% for ProScoreCDS-appropriate and 67.7% and 76.0% for ProScoreCDS-inappropriate, respectively. A scoring system to determine whether CDS is proportionally appropriate can be constructed, and a further study to develop a clinical tool is promising.
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http://dx.doi.org/10.1089/jpm.2020.0773DOI Listing
September 2021

"The surprise questions" using variable time frames in hospitalized patients with advanced cancer.

Palliat Support Care 2021 Jun 17:1-5. Epub 2021 Jun 17.

Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

Objective: Several studies supported the usefulness of "the surprise question" in terms of 1-year mortality of patients. "The surprise question" requires a "Yes" or "No" answer to the question "Would I be surprised if this patient died in [specific time frame]." However, the 1-year time frame is often too long for advanced cancer patients seen by palliative care personnel. "The surprise question" with shorter time frames is needed for decision making. We examined the accuracy of "the surprise question" for 7-day, 21-day, and 42-day survival in hospitalized patients admitted to palliative care units (PCUs).

Method: This was a prospective multicenter cohort study of 130 adult patients with advanced cancer admitted to 7 hospital-based PCUs in South Korea. The accuracy of "the surprise question" was compared with that of the temporal question for clinician's prediction of survival.

Results: We analyzed 130 inpatients who died in PCUs during the study period. The median survival was 21.0 days. The sensitivity, specificity, and overall accuracy for the 7-day "the surprise question" were 46.7, 88.7, and 83.9%, respectively. The sensitivity, specificity, and overall accuracy for the 7-day temporal question were 6.7, 98.3, and 87.7%, respectively. The c-indices of the 7-day "the surprise question" and 7-day temporal question were 0.662 (95% CI: 0.539-0.785) and 0.521 (95% CI: 0.464-0.579), respectively. The c-indices of the 42-day "the surprise question" and 42-day temporal question were 0.554 (95% CI: 0.509-0.599) and 0.616 (95% CI: 0.569-0.663), respectively.

Significance Of Results: Surprisingly, "the surprise questions" and temporal questions had similar accuracies. The high specificities for the 7-day "the surprise question" and 7- and 21-day temporal question suggest they may be useful to rule in death if positive.
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http://dx.doi.org/10.1017/S1478951521000766DOI Listing
June 2021

The Association of Family Functioning With Possible Major Depressive Disorders and Complicated Grief Among Bereaved Family Members of Patients With Cancer: Results From the J-HOPE4 Study, a Nationwide Cross-Sectional Follow-Up Survey in Japan.

J Pain Symptom Manage 2021 Jun 10. Epub 2021 Jun 10.

Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan.

Context: Family functioning is a modifiable factor associated with major depressive disorder (MDD) and complicated grief (CG) among the bereaved families of patients with advanced cancer; however, the evidence regarding this association is limited.

Objectives: We aimed to explore the association of family functioning with possible MDD and CG among the bereaved families of patients with advanced cancer who died in palliative care units.

Methods: This study is a part of the J-HOPE4 study, a nationwide cross-sectional multi-purpose questionnaire survey conducted in 2018. We recruited potential participants from 164 inpatient palliative care units in Japan and assessed family functioning with the Family Relations Index (FRI). Family functioning was classified into three categories (Well-functioning: FRI ≥ 10, Intermediate: FRI = 8〜9, Dysfunctioning ≤ 7). The Patient Health Questionnaire 9 (PHQ-9) and the Brief Grief Questionnaire (BGQ) were used to assess depression (PHQ-9 score ≥ 10) and complicated grief (BGQ score ≥ 8), respectively. Multinomial logistic regression analysis was performed with possible MDD and CG and factors the family functioning.

Results: A total of 615 questionnaires were returned, of which 54.0 % (n = 510) age of questionnaires could be used. Although family functioning was associated with possible MDD (21.1% in Dysfunctional; 9.3% in Well-functional, P = 0.016), it was not associated with possible CG (14.8% in Dysfunctional; 9.9% in Well-functional, P = 0.929). Possible MDD and CG were significantly associated with deteriorated family relationships (OR:8.29; P = 0.004 and OR:34.00; P < 0.001, respectively), and consulting with health care providers about their concerns (OR:0.23; P = 0.003 and OR:0.23; P = 0.003, respectively).

Conclusions: Family function was affected by post-bereavement possible MDD and not by CG. Our findings suggest that health care providers can identify risk factors for MDD among bereaved, dysfunctional family members.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.06.006DOI Listing
June 2021

Effects of an Indomethacin Oral Spray on Pain Due to Oral Mucositis in Cancer Patients Treated With Radiotherapy and Chemotherapy: A Double-Blind, Randomized, Placebo-Controlled Trial (JORTC-PAL04).

J Pain Symptom Manage 2021 09 28;62(3):537-544. Epub 2021 Jan 28.

Department of Palliative Medicine, Kobe University School of Medicine.

Context: Oral mucositis (OM) pain due to anticancer chemo- and radiotherapy has a very negative impact on patient quality of life. However, no high-quality studies have been performed regarding the analgesic efficacy of indomethacin (IM) oral spray for OM pain.

Objectives: This randomized, placebo-controlled, double-blind trial aimed to evaluate the analgesic efficacy of IM oral spray for OM pain due to anticancer chemo- and radiotherapy.

Methods: From July 2015 to December 2016, we enrolled adult cancer patients with OM pain that was due to anticancer chemo- or radiotherapy and was rated 4 or higher on Brief Pain Inventory (BPI) Item 5. Patients were randomly assigned in a 1:1 ratio to receive either IM oral spray or placebo. The primary endpoint was the change in the BPI Item 6 ("current pain") score from before to 30 minutes after treatment. Secondary endpoints were the areas under the curves of BPI Item 6 at 15, 60, 120, 180, and 240 minutes after treatment; five items related to meals and conversation from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire, Head and Neck Module 35; the Clinical Global Impressions-Improvement (CGI-I) scale; and adverse events.

Results: A total of 60 patients were assigned to receive IM oral spray (n = 33) or placebo spray (n = 27). The average change in the BPI item 6 score from before to 30 minutes after treatment was -1.85 (95% confidence interval: -2.37 to -1.32) in the IM spray group and -0.59 (-1.02 to -0.16) in the placebo group, indicating a significant difference (-1.26, -1.94 to -0.57, P < 0.01). The pain improvement persisted for 180 minutes. The intergroup differences in ability to drink liquids, ease in conversing, and CGI-I were all significant (P = 0.03, P = 0.02, and P < 0.01, respectively). No serious adverse events were reported.

Conclusion: IM oral spray alleviated short-term OM pain due to anticancer chemo- and radiotherapy, and may reduce the difficulty in eating meals.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.01.123DOI Listing
September 2021

Differences among institutions in the prevalence of and indications for urinary catheterization of advanced cancer patients at palliative care units: A multicenter prospective cohort study (EASED).

Palliat Med 2021 04 21;35(4):799-805. Epub 2021 Jan 21.

Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.

Background: Studies on the appropriate use of urinary catheters for cancer patients at the end of life are limited.

Aim: To clarify the differences among institutions in the prevalence of and indications for urinary catheterization of advanced cancer patients at palliative care units.

Design: Pre-planned secondary analysis of a multicenter, prospective cohort study; East-Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED).

Setting/participants: This study enrolled consecutive advanced cancer patients admitted to palliative care units between January and December 2017. The final study group comprised 1212 patients from 21 institutions throughout Japan.

Results: Out of the 1212 patients, 380 (31.4%; 95% confidence interval, 28.7%-34.0%) underwent urinary catheterization during their palliative care unit stay, and the prevalence of urinary catheterization in patients who died at palliative care units by institution ranged from 0.0% to 55.4%. When the 21 participating institutions were equally divided into three groups according to the institutional prevalence of catheterization, patients with difficulty in moving safely, exhaustion on movement, and restlessness or agitation were more likely to be catheterized in institutions with a high prevalence of catheterization than in those with a low or moderate prevalence ( < 0.008,  = 0.008, and  < 0.008, respectively).

Conclusion: This study revealed that the institutional prevalence of urinary catheterization in advanced cancer patients at palliative care units widely varied. Further studies are needed to establish the appropriate use of urinary catheters, especially in patients with difficulty in moving safely, exhaustion on movement, and restlessness or agitation.
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http://dx.doi.org/10.1177/0269216321989564DOI Listing
April 2021

Comparison of the prevalence and associated factors of hyperactive delirium in advanced cancer patients between inpatient palliative care and palliative home care.

Cancer Med 2021 02 12;10(3):1166-1179. Epub 2020 Dec 12.

Shinjo-clinic, Hyogo, Japan.

Background: Hyperactive delirium is known to increase family distress and the burden on health care providers. We compared the prevalence and associated factors of agitated delirium in advanced cancer patients between inpatient palliative care and palliative home care on admission and at 3 days before death.

Methods: This was a post hoc exploratory analysis of two multicenter, prospective cohort studies of advanced cancer patients, which were performed at 23 palliative care units (PCUs) between Jan and Dec 2017, and on 45 palliative home care services between July and Dec 2017.

Results: In total, 2998 patients were enrolled and 2829 were analyzed in this study: 1883 patients in PCUs and 947 patients in palliative home care. The prevalence of agitated delirium between PCUs and palliative home care was 5.2% (95% CI: 4.2% - 6.3%) vs. 1.4% (0.7% - 2.3%) on admission (p < 0.001) and 7.6% (6.4% - 8.9%) vs. 5.4% (4.0% - 7.0%) 3 days before death (p < 0.001). However, multivariate logistic regression analysis revealed that the place of care was not significantly associated with the prevalence of agitated delirium at 3 days before death after adjusting for prognostic factors, physical risk factors, and symptoms.

Conclusions: There was no significant difference in the prevalence of agitated delirium at 3 days before death between inpatient palliative care and palliative home care after adjusting for the patient background, prognostic factors, symptoms, and treatment.
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http://dx.doi.org/10.1002/cam4.3661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897964PMC
February 2021

HOme-based Longitudinal Investigation of the multidiSciplinary Team Integrated Care (HOLISTIC): protocol of a prospective nationwide cohort study.

BMC Geriatr 2020 11 27;20(1):511. Epub 2020 Nov 27.

Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, 350, Taiwan.

Background: The use of home health care (HHC) is increasing worldwide. This may have an impact not only on patients and their caregivers' health but on care resource utilization and costs. We lack information on the impact of HHC on the broader dimensions of health status and care resource utilization. More understanding of the longitudinal HHC impact on HHC patients and caregivers is also needed. Moreover, we know little about the synergy between HHC and social care. Therefore, the present study aims to observe longitudinal changes in health, care resource utilization and costs and caregiving burden among HHC recipients and their caregivers in Taiwan.

Methods: A prospective cohort study "Home-based Longitudinal Investigation of the Multidisciplinary Team Integrated Care (HOLISTIC)" will be conducted and 600 eligible patient-caregiver dyads will be recruited and followed with comprehensive quantitative assessments during six home investigations over two years. The measurements include physical function, psychological health, cognitive function, wellbeing, shared decision making and advance care planning, palliative care and quality of dying, caregiving burden, continuity and coordination of care, care resource utilization, and costs.

Discussion: The HOLISTIC study offers the opportunity to comprehensively understand longitudinal changes in health conditions, care resource utilization and costs and caregiving burden among HHC patients and caregivers. It will provide new insights for clinical practitioners and policymakers.

Trial Registration: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.
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http://dx.doi.org/10.1186/s12877-020-01920-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694342PMC
November 2020

Development of medication regimen complexity index: Japanese version and application in elderly patients.

Int J Clin Pharm 2021 Aug 2;43(4):858-863. Epub 2020 Nov 2.

Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.

Background Medication regimen complexity includes various aspects of a regimen, including the dosage form, number of medications and need for additional information for use. Complicated medication regimens cause non-adherence to prescribed medications, making it essential to evaluate medication regimen complexity in older adults to improve adherence to prescribed medications and clinical outcomes. The medication regimen complexity index is currently the most widely used scale for quantifying regimen complexity; however, it has yet to be adopted in Japan. Objective This study aimed to translate the medication regimen complexity index to Japanese and assess its reliability and validity for application in elderly patients in Japan. Setting This study was conducted in a clinic that provides home medical care to patients in the southern part of Ibaraki prefecture, Japan. Method The validation process consisted of translation of the original English version of the medication regimen complexity index to Japanese followed by back-translation to English, comparison of the back-translated and original versions, pilot testing, and assessment of the Japanese version by two raters using the medication regimens of 72 patients with chronic diseases. Main outcome measure The psychometric properties of the index were evaluated according to inter-rater and test-retest reliability, and convergent and discriminant validity. Results The mean age of the 72 patients was 84.3 years. The scale showed high inter-rater reliability (intraclass correlation coefficient 0.946) and test-retest reliability (intraclass correlation coefficient 0.991) for total scores. The number of medications was positively correlated with total medication regimen complexity index score (r = 0.930, P < 0.001). There were no statistically significant differences between age, sex and Charlson Comorbidity Index and medication regimen complexity index score (P > 0.05). Conclusions The Japanese version of the medication regimen complexity index is a reliable and valid tool for assessing the complexity of medication regimen in Japanese elderly patients.
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http://dx.doi.org/10.1007/s11096-020-01185-zDOI Listing
August 2021

Prevalence of Extrapyramidal Symptoms in Cancer Patients Referred to Palliative Care: A Multicenter Observational Study (JORTC PAL12).

Am J Hosp Palliat Care 2021 Jul 17;38(7):823-829. Epub 2020 Sep 17.

Department of Palliative Medicine, 68380Institute of Medical Science, The University of Tokyo, Tokyo, Japan.

Background: Neuroleptics are commonly used in palliative care settings. However, adverse events of neuroleptics, known as extrapyramidal symptoms (EPSs), might be overlooked in clinical practice. We conducted this study to explore the prevalence of EPSs in palliative care setting.

Methods: This multicenter, prospective, observational study included patients who 1) were referred to either a specialist palliative care team or a palliative care unit, 2) had a diagnosis of cancer, and 3) were ≥20 years of age. We investigated the prevalence of EPSs and medications used. The primary outcome was the overall Drug-Induced Extrapyramidal Symptom Scale (DIEPSS) score.

Results: Between November 2015 and October 2016, 149 patients from 5 centers in Japan were enrolled. The median age was 67 years (range: 21-88 years) and the study population included 81 men (54.4%). The cancer types included lung (55 patients, 36.9%), upper gastrointestinal tract (5, 3.3%), hepatobiliary (19, 12.8%); breast (12, 8.1%); head and neck (10, 6.7%), gynecologic (10, 6.7%), genitourinary (10, 6.7%), and others (28, 18.8%). The median Karnofsky performance status was 60 (20-100). Most patients (86.6%) did not experience delirium. Thirty-nine (26.2%) patients received one or more EPS-inducing medications. EPSs occurred in 4 (2.7%) patients with a cutoff score of 5 points for 5 parkinsonism items in DIEPSS.

Conclusion: A lower frequency (<3%) of patients than expected in this population had EPSs. Therefore, we concluded that an interventional study is not feasible. However, medications that cause EPSs are often used in palliative care; therefore, a longitudinal study is warranted.

Trial Registration: This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) (UMIN000019810) on 16, November, 2015.
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http://dx.doi.org/10.1177/1049909120960441DOI Listing
July 2021

The association of family functioning and psychological distress in the bereaved families of patients with advanced cancer: a nationwide survey of bereaved family members.

Psychooncology 2021 01 9;30(1):74-83. Epub 2020 Sep 9.

Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.

Objectives: Family conflict and family functioning were regarded as changeable factors associated with complicated grief (CG) and major depressive disorder (MDD) in the bereaved families of patients with advanced cancer, although the evidence is limited. We explored the family functioning associated with CG and MDD developing either independently or co-morbidly in the bereaved families of patients with advanced cancer who died in palliative care units (PCUs).

Methods: This study comprised a nationwide cross-sectional questionnaire survey of bereaved family members of cancer patients who died in Japanese PCUs participating in evaluation of the quality of end-of-life care.

Results: A total of 529 questionnaires (69.2%) were returned, and we analyzed a total of 458 responses. A total of 14.2% of participants were considered as having CG, 22.5% as having moderate to severe depression, and 9.6% as having co-morbid symptoms. Multivariate logistic regression analysis revealed that many family members insulted or yelled at one another (odd ratio [OR]: 2.99, p = 0.046; OR:2.57, p = 0.033), and conflict regarding what is meant by a good death (OR:3.60, p = 0.026; OR:4.06, p = 0.004) was significantly positively associated with CG, MDD, and co-morbid symptom.

Conclusions: Specific family conflicts may increase the incidence of CG, MDD, and co-morbid symptoms in the bereaved families of patients with advanced cancer. Our results may encourage health care providers to approach discussions about end-of-life issue with the patient and their family in advance, especially focusing on what is considered a good death for the patient, which may prevent or resolve the family conflict.
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http://dx.doi.org/10.1002/pon.5539DOI Listing
January 2021

Variations in vital signs at the end of life in non-cancer patients: a retrospective study.

Ann Palliat Med 2020 Sep 19;9(5):2678-2683. Epub 2020 Aug 19.

Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.

Background: The prediction of impending death is important for providing appropriate end-of-life care; however, limited information is currently available on the signs of impending death in non-cancer patients. Furthermore, although vital signs are routinely measured in clinical practice, changes in vital signs in the dying phase in non-cancer patients have not yet been elucidated in detail.

Methods: We herein conducted a retrospective study to clarify changes in vital signs before death in noncancer patients. Non-cancer patients who died in a hospital in Japan between April 2017 and April 2018 were examined. Vital signs for up to seven days before death were analyzed, with the average value of each vital sign approximately every twelve hours being plotted. We divided data into two periods: from days -7 to -4 and from day -3 to death. We used a linear mixed model in the two periods, and t-tests were performed to assess whether the gradient of the line across the time variable significantly differed from zero.

Results: Data from 47 non-cancer patients were analyzed. Systolic blood pressure (P<0.001), diastolic blood pressure (P<0.001), and oxygen saturation (P=0.001) significantly decreased from day -3 to death, whereas no significant changes were noted in any vital sign in days -7 to -4.

Conclusions: Based on the present results, changes in blood pressure and oxygen saturation may be useful indicators of prognosis within three days of death. Further research on clinical signs and their diagnostic characteristics for impending death in non-cancer patients is needed.
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http://dx.doi.org/10.21037/apm-20-1054DOI Listing
September 2020

Doctors' professional identity and socialisation from medical students to staff doctors in Japan: narrative analysis in qualitative research from a family physician perspective.

BMJ Open 2020 07 14;10(7):e035300. Epub 2020 Jul 14.

Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.

Objective: Becoming a doctor involves transforming a lay person into a medical professional, which is known as professional socialisation. However, few studies have clarified differences in the professional socialisation process in detail. The aim of this study was to clarify the process of professional socialisation of medical students to residents to staff doctors.

Design: We used narrative analysis in qualitative research as a theoretical framework.

Setting: This study was conducted in Japan.

Participants: Participants were collected using a purposive sample of doctors with over 7 years of medical experience. We conducted semistructured interviews from September 2015 to December 2016, then used a structured approach to integrate the sequence of events into coherent configurations.

Results: Participants were 13 males and 8 females with medical careers ranging from 8 to 30 years. All participants began to seriously consider their own career and embodied their ideal image of a doctor through clinical practice. As residents, the participants adapted as a member of the organisation of doctors. Subsequently, doctors exhibited four patterns: first, they smoothly transitioned from 'peripheral' to 'full' participation in the organisation; second, they could no longer participate peripherally but developed a professional image from individual social interactions; third, they were affected by outsiders' perspectives and gradually participated peripherally; fourth, they could not regard the hospital as a legitimate organisation and could not participate fully.

Conclusion: The professional socialisation process comprises an institutional theory, professional persona, legitimate peripheral participation and threshold concepts. These findings may be useful in supporting professional development.
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http://dx.doi.org/10.1136/bmjopen-2019-035300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365484PMC
July 2020

Determinants of Physicians' Attitudes Toward the Management of Infectious Diseases in Terminally Ill Patients With Cancer.

J Pain Symptom Manage 2020 12 4;60(6):1109-1116.e2. Epub 2020 Jul 4.

Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.

Objectives: Antimicrobials are frequently prescribed to terminally ill patients with cancer; however, physicians' practice patterns regarding antimicrobial use vary widely. This study aimed to systematically identify factors that determine physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer.

Methods: A nationwide cross-sectional survey involving 600 oncologists, 600 infectious diseases physicians, 600 palliative care physicians, and 220 home care physicians was conducted between November 2017 and January 2018. The primary endpoint was physicians' attitudes toward the management of infectious diseases in terminally ill patients with cancer with a few weeks of prognosis. Physicians' beliefs regarding management of infectious diseases as well as physician-perceived "good death" were also assessed (1 = strongly disagree to 6 = strongly agree).

Results: There were 895 (44.3%) analyzable response, and average scores of physicians' attitudes ranged between 2.69 and 4.32. In total, 241 (27%; 95% CI = 24-30) to 691 (78%; 95% CI = 75-81) respondents showed proactive attitudes toward various infectious diseases management. In linear regression analysis, determinants of proactive attitudes included the following: physicians' belief that examination and treatment will improve quality of life and prognosis and reduce suffering (β = 0.32, t = 9.99, P = 0.00); greater physician-perceived importance on receiving enough treatment (β = 0.09, t = 2.88, P = 0.00) and less importance on dying a natural death (β = -0.07, t = -2.14, P = 0.03) for a "good death"; working at a tertiary care hospital (β = 0.16, t = 4.40, P = 0.00); and not being a home care physician (β = -0.20, t = -5.51, P = 0.00) or palliative care physician (β = -0.12, t = -3.64, P = 0.00).

Conclusions: Physicians have divergent attitudes toward the management of infectious diseases in terminally ill patients with cancer. Reflection by physicians on their own beliefs and perceptions regarding infectious disease management and a "good death" may help provide the best end-of-life care.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.06.041DOI Listing
December 2020

The Principles of Revised Clinical Guidelines about Palliative Sedation Therapy of the Japanese Society for Palliative Medicine.

J Palliat Med 2020 09 13;23(9):1184-1190. Epub 2020 Apr 13.

Department of Palliative Medicine, Yodogawa Christian Hospital, Osaka, Japan.

When the suffering of a terminally ill patient is intolerable and refractory, sedatives are sometimes used for symptom relief. To describe the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Consensus methods using the Delphi technique were used. The main principles of the guidelines that were newly defined or developed are as follows: (1) palliative sedation was defined as "administration of sedatives for the purpose of alleviating refractory suffering" (excluding the aim of reducing patient consciousness); (2) palliative sedation was classified according to the method of administration of sedatives: respite sedation versus continuous sedation (including (continuous) proportional sedation and continuous deep sedation); (3) a description of state-of-the-art recommended treatments for difficult symptoms such as delirium, dyspnea, and pain before the symptom was determined as refractory was included; (4) the principle of proportionality was newly defined from an ethical point of view; and (5) families' consent was regarded as being desirable (mandatory in the previous version). We described the main principles of revised Japanese clinical guidelines about palliative sedation therapy. Further consensus building is necessary.
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http://dx.doi.org/10.1089/jpm.2019.0626DOI Listing
September 2020

End-of-life care preferences of the general public and recommendations of healthcare providers: a nationwide survey in Japan.

BMC Palliat Care 2020 Mar 24;19(1):38. Epub 2020 Mar 24.

Faculty of Medicine, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, 305-8575, Ibaraki, Japan.

Background: A better understanding of differences between the preferences of the general public and the recommendations of healthcare providers with regard to end-of-life (EOL) care may facilitate EOL discussion.

Methods: The aim of this study was to clarify differences between preferences of the general public and recommendations of healthcare providers with regard to treatment, EOL care, and life-sustaining treatment (LST) based on a hypothetical scenario involving a patient with advanced cancer. This study comprised exploratory post-hoc analyses of "The Survey of Public Attitude Towards Medical Care at the End of life", which was a population based, cross-sectional anonymous survey in Japan to investigate public attitudes toward medical care at the end of life. Persons living in Japan over 20 years old were randomly selected nationwide. Physicians, nurses, and care staff were recruited at randomly selected facilities throughout Japan. The general public data from the original study was combined to the data of healthcare providers in order to conduct exploratory post-hoc analyses. The preferences of the general public and recommendations of healthcare providers with regard to EOL care and LST was assessed based on the hypothetical scenario of an advanced cancer patient.

Results: All returned questionnaires were analyzed: 973 from the general public, 1039 from physicians, 1854 from nurses, and 752 from care staff (response rates of 16.2, 23.1, 30.9, and 37.6%, respectively). The proportion of the general public who wanted "chemotherapy or radiation", "ventilation", and "cardiopulmonary resuscitation" was significantly higher than the frequency of these options being recommended by physicians, nurses, and care staff, but the general public preference for "cardiopulmonary resuscitation" was significantly lower than the frequency of its recommendation by care staff.

Conclusion: Regarding a hypothetical scenario for advanced cancer, the general public preferred more aggressive treatment and more frequent LST than that recommended by healthcare providers.
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http://dx.doi.org/10.1186/s12904-020-00546-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7093951PMC
March 2020

Frequency of discussing and documenting advance care planning in primary care: secondary analysis of a multicenter cross-sectional observational study.

BMC Palliat Care 2020 Mar 17;19(1):32. Epub 2020 Mar 17.

Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.

Background: To improve the quality of advance care planning (ACP) in primary care, it is important to understand the frequency of and topics involved in the ACP discussion between patients and their family physicians (FPs).

Methods: A secondary analysis of a previous multicenter cross-sectional observational study was performed. The primary outcome of this analysis was the frequency of and topics involved in the ACP discussion between outpatients and FPs. In March 2017, 22 family physicians at 17 clinics scheduled a day to assess outpatients and enrolled patients older than 65 years who were recognized by FPs as having regular visits. We defined three ACP discussion topics: 1) future decline in activities of daily living (ADL), 2) future inability to eat, and 3) surrogate decision makers. FPs assessed whether they had ever discussed any ACP topics with each patient and their family members, and if they had documented the results of these discussions in medical records before patients were enrolled in the present study. We defined patients as being at risk of deteriorating and dying if they had at least 2 positive general indicators or at least 1 positive disease-specific indicator in the Japanese version of the Supportive and Palliative Care Indicators Tool.

Results: In total, 382 patients with a mean age of 77.4 ± 7.9 years were enrolled, and 63.1% were female. Seventy-nine patients (20.7%) had discussed at least one ACP topic with their FPs. However, only 23 patients (6.0%) had discussed an ACP topic with family members and their FPs, with the results being documented in their medical records. The topic of future ADL decline was discussed and documented more often than the other two topics. Patients at risk of deteriorating and dying discussed ACP topics significantly more often than those not at risk of deteriorating and dying (39.4% vs. 16.8%, p < 0.001).

Conclusion: FPs may discuss ACP with some of their patients, but may not often document the results of this discussion in medical records. FPs need to be encouraged to discuss ACP with patients and family members and describe the decisions reached in medical records.
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http://dx.doi.org/10.1186/s12904-020-00543-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079526PMC
March 2020

Changes in Body Mass Index, Energy Intake, and Fluid Intake over 60 Months Premortem as Prognostic Factors in Frail Elderly: A Post-Death Longitudinal Study.

Int J Environ Res Public Health 2020 03 11;17(6). Epub 2020 Mar 11.

Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan.

Survival prediction is considered difficult in elderly individuals with cognitive frailty or dementia that leads to death. The aim of this study was to verify temporal changes in body mass index (BMI), energy intake, and fluid intake measured continuously in frail elderly people as prognostic factors for death. We assessed 106 frail elderly individuals who received >2-year care at an elderly care facility and died at the facility. We analyzed temporal changes in BMI, energy intake, and fluid intake from a maximum of 60 months premortem to death and determined the relationship between these parameters. BMI was significantly below the reference values from 9 months prior to death, but energy intake remained constant from 2 months prior to death to death ( < 0.001). However, the mean fluid intake decreased suddenly immediately prior to death. We compared the changes in each parameter during the year prior to death and during the preceding year and found significant differences in all parameters ( < 0.001). From 60 months prior to death to death, BMI, energy intake, and fluid intake decreased in the same order over time. Therefore, these parameters can be used as prognostic factors for death in frail elderly people.
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http://dx.doi.org/10.3390/ijerph17061823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7142819PMC
March 2020

Survival time after marked reduction in oral intake in terminally ill noncancer patients: A retrospective study.

J Gen Fam Med 2020 Mar 6;21(2):9-14. Epub 2019 Dec 6.

Faculty of Medicine Division of Clinical Medicine University of Tsukuba Tsukuba Ibaraki Japan.

Background: The prediction of short-term survival is important for noncancer patients and their families. Although a markedly reduced oral intake by cancer patients suggests a poor prognosis, the survival times of noncancer patients after its onset remain unclear. We herein investigated the time from a marked reduction in oral intake to death in noncancer patients as well as factors associated with their subsequent survival.

Methods: We conducted a retrospective medical record review of noncancer patients who died in our hospital between April 2017 and April 2018. We recorded the day when oral intake markedly decreased and the date of death. We extracted data on age, gender, the Charlson Comorbidities Index, mean daily fluid volume, laboratory test results, and vital signs converted to the Shock Index (SI). We used Cox's proportional hazards models to assess relationships between these factors and survival times after the onset of a markedly reduced oral intake.

Results: We analyzed data from 44 noncancer patients. The median time from the onset of a markedly reduced oral intake to death was 16.5 days. Based on Cox's proportional hazards models, only SI ≧ 1.0 at the onset of a markedly reduced oral intake correlated with survival times (hazard ratio: 5.89, 95% confidence interval (CI): 1.71-20.1,  = .005).

Conclusion: Noncancer patients died a median of 16.5 days after the onset of a markedly reduced oral intake, and SI ≧1.0 correlated with subsequent survival times. These results will provide novel insights into the prognosis of noncancer patients at the end of life.
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http://dx.doi.org/10.1002/jgf2.290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7060293PMC
March 2020

Current Engagement in Advance Care Planning in Japan and Its Associated Factors.

Gerontol Geriatr Med 2019 Jan-Dec;5:2333721419892694. Epub 2019 Dec 20.

University of Tsukuba, sukuba, Ibaraki, Japan.

Using the Ministry of Health, Labour and Welfare national data on perspectives toward medical care at the end of life, this study examined the current status of engagement in advance care planning (ACP) activities among physicians and nurses in Japan and associated factors. Only 28.7% of physicians and 27.6% of nurses answered that they were engaging their patients/clients in ACP. Multinomial regression analysis revealed that more frequent involvement in caring for dying patients was associated with ACP engagement for both physicians and nurses. Increased years of clinical practice experience and working in a hospital were associated with decreased likelihood of nurses' ACP engagement. Completion of training designed to promote patient self-determination at the end of life was associated with both physicians' and nurses' ACP engagement. It is recommended that health care professionals be encouraged to complete such training to promote patients' autonomy through ACP.
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http://dx.doi.org/10.1177/2333721419892694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926984PMC
December 2019

Attitudes and Other Factors Influencing End-of-Life Discussion by Physicians, Nurses, and Care Staff: A Nationwide Survey in Japan.

Am J Hosp Palliat Care 2020 Apr 29;37(4):258-265. Epub 2019 Sep 29.

Faculty of Medicine, University of Tsukuba, Japan.

Context: Better understanding about the attitudes of health-care providers toward end-of-life discussion would facilitate the development of systematic strategies for improving end-of-life care.

Objective: To clarify attitudes toward end-of-life discussion with patients near death and explore the factors influencing these attitudes among physicians, nurses, and care staff.

Methods: This study was part of a nationwide cross-sectional anonymous survey of the public attitudes toward end-of-life medical care performed in December 2017. The participants were physicians, nurses, and care staff from randomly selected facilities, including hospitals, clinics, home-visit nursing offices, nursing homes, and long-term care facilities throughout Japan. The questionnaire was sent to 4500 physicians, 6000 nurses, and 2000 care staff. We assessed attitudes about end-of-life discussion with patients near death, identification of the proxy decision maker, and sharing documented information on end-of-life discussion with the multidisciplinary team.

Results: We analyzed responses from 1012 physicians, 1824 nurses, and 749 care staff. The number of responders who considered they had adequate end-of-life discussion with patients near death was 281 (27.8%), 324 (17.8%), and 139 (18.6%), respectively. Participation in a nationwide education program and caring for at least 1 dying patient per month were factors that showed a significant association with adequate end-of-life discussion and identification of the proxy decision maker.

Conclusions: The percentages of physicians, nurses, and care staff involved in adequate end-of-life discussion with patients near death were not high. Participation in a structured education program might have a positive influence on end-of-life discussion with patients.
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http://dx.doi.org/10.1177/1049909119876568DOI Listing
April 2020

Associated factors for discussing advance directives with family physicians by noncancer outpatients in Japan.

J Gen Fam Med 2019 May 20;20(3):82-92. Epub 2019 Feb 20.

Faculty of Medicine University of Tsukuba Tsukuba Japan.

Background: Advance directives (ADs) are seldom discussed between primary care physicians (PCPs) and their patients, especially those with noncancer diseases. The aim was to identify the factors associated with discussing AD by noncancer patients with their physicians.

Methods: This cross-sectional study was conducted in a hospital or clinic from October to December 2017. Physicians chose eligible noncancer patients aged 20 years or older to respond to an anonymous self-completed questionnaire inquiring about the objective variable "I want to discuss AD with my doctor," as well as basic characteristics, and facilitators and barriers to discussing AD identified in previous studies. The physicians responded to a survey comprising the Palliative Performance Scale (PPS) and inquiring about the disease category for each patient. Data were analyzed using binomial logistic regression analysis.

Results: A total of 270 patients (valid response rate, 79.6%) were included. Multivariate analysis identified a period of visit to the study site ≥ 3 years (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.05-4.10), physicians who are very good at taking care of patients' disease (OR, 12.68; 95% CI, 1.12-143.22), and patients' worry about their quality of life (QOL) in the future (OR, 2.69; 95% CI, 1.30-5.57) as facilitators for discussing AD with physicians, and PPS ≤ 90 (OR, 0.51; 95% CI, 0.26-0.98) as a barrier.

Conclusions: Our study indicates that patients' future QOL concerns, a long period of visit to a hospital, and the presence of physical symptoms were associated with the willingness of noncancer patients to discuss AD with PCPs.
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http://dx.doi.org/10.1002/jgf2.238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6498101PMC
May 2019

The Effects of Adding Reassurance Statements: Cancer Patients' Preferences for Phrases in End-of-Life Discussions.

J Pain Symptom Manage 2019 06 25;57(6):1121-1129. Epub 2019 Feb 25.

Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan; Innovation Center for Supportive, Palliative and Psychosocial Care, National Cancer Center Hospital, Tokyo, Japan.

Context: When discussing end-of-life issues with cancer patients, the addition of reassurance statements is considered helpful. However, patients' preferences for such statements have not been systematically demonstrated.

Objectives: The objectives of this study were to clarify if phrases with additional reassurance statements would be more preferable to phrases without them and explore variables associated with patients' preferences.

Methods: In a cross-sectional survey, 412 cancer patients assessed their own preferences for phrases with/without additional statements using a six-point scale (1 = not at all preferable; 6 = very preferable). These included the statements of "hope for the best and prepare for the worst" ("hope/prepare") when discussing prognosis; symptom palliation when discussing code status; and specific goals, continuity of care, and nonabandonment when discussing hospice referral. We evaluated demographic data and the coping style and conducted multivariate regression analysis.

Results: Compared with the phrase of life expectancy (i.e., median + typical range) alone [mean (SD), 3.5 (1.2); 95% CI, 3.4-3.6], the phrase with the additional "hope/prepare" statement was more preferable [3.8 (1.4); 3.7-3.9]. Compared with the phrase of do-not-resuscitate alone (3.1(1.3); 3.0-3.3), the phrase with the additional statement of symptom palliation was more preferable [3.9 (1.3); 3.7-4.0]. Compared with the phrase of hospice referral alone [3.4 (1.2); 3.3-3.5], phrases with the addition of a specific goal [3.9 (1.0); 3.8-4.0], specific goal and continuity (4.4(1.0); 4.3-4.5), and specific goal, continuity, and nonabandonment [4.8 (1.2); 4.7-4.9] were more preferable. In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases including additional reassurance statements.

Conclusion: Cancer patients systematically preferred reassurance statements. In end-of-life discussions, especially with patients with task-oriented coping, clinicians may provide additional reassurance statements.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.02.019DOI Listing
June 2019

Adding a Wider Range and "Hope for the Best, and Prepare for the Worst" Statement: Preferences of Patients with Cancer for Prognostic Communication.

Oncologist 2019 09 19;24(9):e943-e952. Epub 2019 Feb 19.

Division of Cohort Consortium Research, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan.

Introduction: Although various phrases to communicate prognoses based on a certain concept have been proposed, no study has systematically investigated preferences of patients with cancer for actual phrases. We investigated whether phrases with a wider range and additional "hope for the best, and prepare for the worst" (hope/prepare) statement would be more preferable and explored variables associated with patients' preferences.

Materials And Methods: In a cross-sectional survey, 412 outpatients with cancer self-assessed their preferences for 13 phrases conveying prognostic information (e.g., phrases with or without median, typical range, and/or best/worst cases, and those with or without a hope/prepare statement) on a 6-point scale (1 = not at all preferable; 6 = very preferable). We evaluated demographic data and the Coping Inventory for Stressful Situations and conducted multivariate regression analysis.

Results: Regarding phrases with various ranges, the one including the median, typical range, and best/worst cases was more preferable (mean ± SD, 3.8 ± 1.3; 95% confidence interval [CI], 3.6-3.9) than the one with the median and typical range (3.4 ± 1.2; 3.3-3.6) or the one with only the median (3.2 ± 1.3; 3.1-3.3). Concerning the hope/prepare statement, the phrase including the median, typical range, uncertainty, and hope/prepare statement was more preferable (3.8 ± 1.4; 3.7-3.9) than the one without the statement (3.5 ± 1.2; 3.4-3.6). In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases with explicit information.

Conclusion: Overall, phrases with a wider range and the hope/prepare statement were preferable to those without them. When patients with cancer ask about prognoses, especially those with task-oriented coping, clinicians may provide explicit information with a wider range and the hope/prepare statement.

Implications For Practice: Discussing prognoses with patients with advanced cancer is among the most important conversations for clinicians. In this cross-sectional survey to systematically investigate preferences of 412 patients with cancer for phrases conveying prognostic information, phrases with the median, typical range, and best/worst cases and those with the "hope for the best and prepare for the worst" (hope/prepare) statement were the most preferred. When patients with cancer ask about prognoses, clinicians may provide explicit information with a wider range and include the hope/prepare statement.
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http://dx.doi.org/10.1634/theoncologist.2018-0643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738294PMC
September 2019

Prevalence of obstructive sleep apnea in primary care patients with hypertension.

J Gen Fam Med 2019 Jan 24;20(1):39-42. Epub 2018 Oct 24.

Muribushi Project for Okinawa Residency Programs Okinawa Japan.

Background: As the number of patients with hypertension who have obstructive sleep apnea (OSA) might be underestimated, this study aimed to explore the prevalence of OSA and develop a diagnostic algorithm for moderate or severe OSA among primary care (PC) patients with hypertension.

Methods: This multicenter cross-sectional study enrolled patients diagnosed with hypertension aged 18 years or older in Japan from October 2012 to September 2014.

Results: Forty-nine patients (64.5%) had 22 or more obstructive respiratory events during sleep.

Conclusions: The prevalence of OSA among PC patients with hypertension might be much higher than previously thought.
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http://dx.doi.org/10.1002/jgf2.214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6321825PMC
January 2019

Prevalence and Characteristics of Patients Being at Risk of Deteriorating and Dying in Primary Care.

J Pain Symptom Manage 2019 02 15;57(2):266-272.e1. Epub 2018 Nov 15.

Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan.

Context: Understanding the prevalence and characteristics of primary care outpatients being at risk of deteriorating and dying may allow general practitioners (GPs) to identify them and initiate end-of-life discussions.

Objectives: This study aimed to investigate the prevalence and characteristics of primary care outpatients being at risk of deteriorating and dying, as determined by the Supportive and Palliative Care Indicators Tool (SPICT™).

Methods: A multicenter cross-sectional observational study was conducted at 17 clinics with 22 GPs. We enrolled all patients aged ≥65 years who visited the GPs in March 2017. We used the Japanese version of the SPICT to identify patients being at risk of deteriorating and dying. We assessed the demographic and clinical characteristics of enrolled patients.

Results: In total, 382 patients with a mean age of 77.4 ± 7.9 years were investigated. Sixty-six patients (17.3%) had ≥2 positive general indicators or ≥1 positive disease-specific indicator in the SPICT-JP. Patients with dementia/frailty, neurological disease, cancer, and kidney disease showed a significantly elevated risk of deteriorating and dying, whereas patients with other specific disease did not. The patients at risk were significantly older and less likely to be living with family at home. They also had a higher Charlson Comorbidity Index score and a lower Palliative Performance Scale score.

Conclusion: Among primary care outpatients aged over 65 years, 17.3% were at risk of deteriorating and dying regardless of their estimated survival time, and many outpatients at risk were not receiving optimal multidisciplinary care.
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http://dx.doi.org/10.1016/j.jpainsymman.2018.11.006DOI Listing
February 2019

A combination of routine laboratory findings and vital signs can predict survival of advanced cancer patients without physician evaluation: a fractional polynomial model.

Eur J Cancer 2018 12 2;105:50-60. Epub 2018 Nov 2.

Department of Palliative and Supportive Care, Palliative Care Team, Seirei Hospice, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka 433-8558, Japan. Electronic address:

Introduction: There have been no reports about predicting survival of patients with advanced cancer constructed entirely with objective variables. We aimed to develop a prognostic model based on laboratory findings and vital signs using a fractional polynomial (FP) model.

Methods: A multicentre prospective cohort study was conducted at 58 specialist palliative care services in Japan from September 2012 to April 2014. Eligible patients were older than 20 years and had advanced cancer. We developed models for predicting 7-day, 14-day, 30-day, 56-day and 90-day survival by using the FP modelling method.

Results: Data from 1039 patients were analysed to develop each prognostic model (Objective Prognostic Index for advanced cancer [OPI-AC]). All models included the heart rate, urea and albumin, while some models included the respiratory rate, creatinine, C-reactive protein, lymphocyte count, neutrophil count, total bilirubin, lactate dehydrogenase and platelet/lymphocyte ratio. The area under the curve was 0.77, 0.81, 0.90, 0.90 and 0.92 for the 7-day, 14-day, 30-day, 56-day and 90-day model, respectively. The accuracy of the OPI-AC predicting 30-day, 56-day and 90-day survival was significantly higher than that of the Palliative Prognostic Score or the Prognosis in Palliative Care Study model, which are based on a combination of symptoms and physician estimation.

Conclusion: We developed highly accurate prognostic indexes for predicting the survival of patients with advanced cancer from objective variables alone, which may be useful for end-of-life management. The FP modelling method could be promising for developing other prognostic models in future research.
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http://dx.doi.org/10.1016/j.ejca.2018.09.037DOI Listing
December 2018

Talking About Palliative Sedation With the Family: Informed Consent vs. Assent and a Better Framework for Explaining Potential Risks.

J Pain Symptom Manage 2018 09 15;56(3):e5-e8. Epub 2018 May 15.

Innovation Center for Supportive, Palliative and Psychosocial Care, Department of Psycho-Oncology, National Cancer Center Hospital, Tsukiji, Chuo-ku, Tokyo, Japan.

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http://dx.doi.org/10.1016/j.jpainsymman.2018.05.004DOI Listing
September 2018

Identified Palliative Care Approach Needs with SPICT in Family Practice: A Preliminary Observational Study.

J Palliat Med 2018 07 9;21(7):992-998. Epub 2018 Feb 9.

3 Department of Palliative Medicine, Kobe University Graduate School of Medicine , Kobe, Japan .

Background: Identifying patients who require palliative care approach is challenging for family physicians, even though several identification tools have been developed for this purpose.

Objective: To explore the prevalence and characteristics of family practice patients who need palliative care approach as determined using Supportive and Palliative Care Indicators Tool (SPICT™, April 2015) in Japan.

Design: Single-center cross-sectional study.

Setting/subjects: We enrolled all patients ≥65 years of age who visited the chief researcher's outpatient clinic in October 2016.

Measurements: We used Japanese version of SPICT (SPICT-J) to identify patients who need palliative care approach. We assessed patients' backgrounds and whether they had undergone advance care planning with their family physicians.

Results: This study included 87 patients (61 females) with a mean age of 79.0 ± 7.4 years. Eight patients (9.2%) were identified as needing palliative care approach. The mean age of patients who needed this approach was 82.3 ± 8.3 years and main underlying conditions were heart/vascular disease (37.5%), dementia/frailty (25.0%), and respiratory disease (12.5%). Only two of eight patients identified as needing palliative care approach had discussed advance care planning with their family physicians.

Conclusions: In family practice, 9.2% of outpatients ≥65 years of age were identified as needing palliative care approach. Family physicians should carefully evaluate whether outpatients need palliative care approach.
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http://dx.doi.org/10.1089/jpm.2017.0491DOI Listing
July 2018
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