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Background: Corticosteroids are often used to treat fatigue and anorexia, but occasionally produce delirium. Information on the predictors of delirium in corticosteroid-treated cancer patients remains limited. Objective: To identify potential factors predicting the development of delirium in corticosteroid-treated cancer patients. Design: An exploratory, multicenter, prospective, observational study. Setting/Subjects: Inclusion criteria for this study were patients who had metastatic or locally advanced cancer and a fatigue or anorexia intensity score of 4 or more on a 0-10 Numerical Rating Scale. Measurement: Univariate and multivariable analyses were performed to identify the predictors of delirium diagnosed by the Confusion Assessment Method (CAM) within three days of initiation of corticosteroids. Results: Among 207 patients administered corticosteroids, 35 (17%; 95% confidence interval [CI] 12%-23%) developed at least one episode of delirium diagnosed by the CAM. Factors predictive of the development of delirium were as follows: Palliative Performance Scale ≤20, Eastern Cooperative Oncology Group Performance Status (ECOG PS) = 4, the Support Team Assessment Schedule (STAS) score of drowsiness >1, concurrent opioid use, parenteral hydration volume ≤500 mL, and the absence of lung metastasis. A multivariable analysis identified the independent factors predicting responses as ECOG PS = 4 (odds ratio [OR] 4.0; 95% CI 1.7-9.3), STAS score of drowsiness >1 (OR 3.4; 95% CI 1.4-8.2), and concurrent opioid use (OR 3.7; 95% CI 1.0-13). Conclusion: Delirium in corticosteroid-treated advanced cancer patients may be predicted by PS, drowsiness, and concurrent opioid use. Larger prospective studies are needed to confirm these results. [ABSTRACT FROM AUTHOR]

Background: Oral administration of medication is often difficult in terminally ill patients with cancer. These patients require intravenous routes for high-dose opioid administration and/or parenteral nutrition. When the superior vena cava (SVC) is unsuitable for central vein catheter insertion (i.e., in patients with mediastinal masses involving the SVC), alternative access routes are needed. Of these, the femoral vein is most utilized. In our experience, the femoral tunneled catheter (FTC) is easy and safe to use. We retrospectively studied FTC outcomes in terminally ill patients with cancer. Materials and methods: Charts of consecutive patients admitted to the palliative care unit between April 2008 and December 2011 were reviewed. FTC is inserted into the vein by the single-puncture method using a 16-gauge catheter with a 14-gauge peel-away introducer. Results: Eleven patients underwent FTC insertion. In total, there were 207 days of FTC placement; the mean period in place was 19±15 days. Eight patients received parenteral opioid therapy, high doses in four cases, via FTCs. Complications were incidental arterial puncture and poor infusion rate due to hip joint bending in one case each. Neither catheter-related infection nor clinical venous thrombosis occurred. Conclusions: FTCs were successfully inserted, with a low complication rate. FTC, a simple technique, might be an acceptable alternative in selected terminally ill patients with cancer, when SVC insertion is difficult or contraindicated. [ABSTRACT FROM AUTHOR]

Background: Although corticosteroids are commonly used for symptom relief in the treatment of patients with advanced cancer, few studies have addressed nationwide physician-reported practices and attitudes toward corticosteroid therapy in palliative care settings. Design and Subjects: To clarify physician-reported practices and attitudes toward corticosteroid therapy for anorexia, fatigue, and dyspnea, a 15-item questionnaire was mailed to all 178 certified palliative care units in Japan. Results: In total, 124 physicians returned questionnaires (response rate of 70%). The median percentage receiving corticosteroids among all terminally ill cancer inpatients was 80% (fatigue, 80%; anorexia, 80%; dyspnea, 80%). Physicians reported varying methods and attitudes regarding corticosteroid use in palliative care settings. Regarding withdrawal when patient death was imminent, 46% of respondents usually abruptly ceased corticosteroid use, while 33% reduced but did not stop administration, and 21% neither stopped nor reduced corticosteroids. As for dosage, 47% of physicians selected a minimum daily dose for fatigue <2 mg, while 51% chose 2-4 mg. As for administration period, 50% started administering corticosteroids for dyspnea regardless of the prognosis, while 30% regarded a predicted survival of less than 3 months to be an indication for corticosteroid treatment. For side effect management, 48% did not principally prescribe corticosteroids for patients with hyperactive delirium, while 44% cautiously prescribed corticosteroids. Conclusion: The use of corticosteroids is very common in Japanese palliative care units, but physicians reported varying practices and attitudes regarding administration protocols. Future studies are needed to determine the standard treatment protocol for corticosteroid use in the terminally ill. [ABSTRACT FROM AUTHOR]

Background and Methods: Corticosteroids are commonly used for symptom relief in the treatment of patients with advanced cancer. Consistent efficacy of corticosteroid treatment in palliative care remains controversial. A cross-sectional anonymous survey was mailed to representative managing physicians in certified palliative care units in Japan to clarify the physician-perceived efficacy of steroid treatment on anorexia, fatigue, and dyspnea in terminal cancer patients, to clarify physicians' experience of side effects of corticosteroid use, and to determine the Japanese palliative care physician-reported predictive factors for efficacy and lack of efficacy. Results and Conclusions: Many Japanese palliative care specialists perceived that corticosteroids are effective for each of the symptoms, are aware of the prevalence and importance of serious adverse effects, and predict the effectiveness of steroid therapy by etiological factors. [ABSTRACT FROM AUTHOR]

Background: Although intravenous midazolam and flunitrazepam are frequently administered for primary insomnia in Japan, there is no empirical study on their efficacy and safety. Design and subjects: To compare the efficacy, safety, and cost-effectiveness of midazolam and flunitrazepam, a multicenter retrospective audit study was performed on 104 and 59 patients receiving midazolam and flunitrazepam, respectively, from 18 certified palliative care units. Results: Median administration periods were 6 days and 9 days for midazolam and flunitrazepam, respectively. The median initial and maximum doses were 10 mg per night and 18 mg per night for midazolam, and 2 mg per night and 2 mg per night for flunitrazepam, respectively. There were no significant differences in the efficacy (91% in the midazolam group versus 81% in the flunitrazepam group, p = 0.084), hangover effect (34% versus 19%, p = 0.094), delirium at night (12% versus 10%, p = 1.0) and delirium next morning (11% versus 15%, p = 0.33), treatment withdrawal (4.8% versus 1.7%, p = 0.41), and treatment-related death (0% versus 0%, p = 1.0). Flunitrazepam caused respiratory depression defined as physician or nurses records such as apnea, respiratory arrest, decreased respiratory rate, and respiratory depression significantly more frequently than midazolam (17% versus 3.8%, p = 0.0073). The maximum dose was more highly correlated with the administration period in the midazolam group than in the flunitrazepam group (ρ = 0.52, versus ρ = 0.39), and, for patients treated for 14 days or longer, the daily escalation dose ratio required for maintaining adequate sleep was significantly higher in the midazolam group than in the flunitrazepam group (11% versus 2.6%, p = 0.015). The costs of the initial and maximum administration were significantly higher in the midazolam group than in the flunitrazepam group ( p < 0.001). Conclusion: Intravenous midazolam and flunitrazepam appeared to be almost equal about efficacy and safety for primary insomnia, but flunitrazepam is less expensive and shows lower risk of tolerance development. A future prospective comparison study is necessary. [ABSTRACT FROM AUTHOR]

Background: Tumor fever and infection are common febrile etiologies among advanced cancer patients. To date, only few studies have been conducted to differentiate between tumor fever and infections. Objective: This study aimed to identify discriminating factors that provide rapid results and are feasible and minimally invasive for discriminating between tumor fever and infection in advanced cancer patients. Methods: This is a retrospective cohort study. Advanced cancer patients with clinically diagnosed tumor fever or infection, who received medical treatment from palliative care specialists in 10 nationwide Japanese hospitals, were consecutively identified during August 2012 and November 2014. The symptoms, physical findings, blood test results at baseline and during fever, imaging findings, and sociodemographic factors of these patients were retrospectively extracted. Results: Thirty-three patients with tumor fever and 72 patients with infection were identified. Their mean age was 68.8 years, 68 (64.8%) were men, and the median palliative performance status (PPS) was 50. Statistically significant factors predicting tumor fever by logistic regression analysis were as follows: deterioration of PPS (odds ratio, 0.078), shaking chills during fever (0.067), and change from baseline data of neutrophil/lymphocyte ratio of ≥5 (0.14). Conclusions: Shaking chills during fever, and changes from baseline of performance status and white blood cell differentiation can be useful to differentiate between tumor fever and infection among advanced cancer patients. Further confirmatory studies are needed. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal symptoms, including nausea, vomiting, bowel obstruction, ascites, constipation, and anorexia, are common and often refractory in advanced cancer patients. The palliation of gastrointestinal symptoms is important in improving the quality of life of cancer patients, as well as that of their families and caregivers. Currently published clinical guidelines for the management of gastrointestinal symptoms in cancer patients do not comprehensively cover the topics or are not based on a formal process for the development of clinical guidelines. Methods: The Japanese Society for Palliative Medicine (JSPM) developed comprehensive clinical guidelines for the management of gastrointestinal symptoms in cancer patients after a formal guideline development process. Results: This article summarizes the recommendations along with their rationale and a short summary of the development process of the JSPM gastrointestinal symptom management guidelines. We established 31 recommendations, all of which are based on the best available evidence and agreement of expert taskforce members. Discussion: Future clinical studies and continuous guideline updates are required to improve gastrointestinal symptom management in cancer patients. [ABSTRACT FROM AUTHOR]