Family experience with palliative sedation therapy for terminally ill cancer patients

Symptomatic sedation is often required in terminally ill cancer patients, and could cause significant distress to their family. The aims of this study were to clarify the family experience during palliative sedation therapy, including their satisfaction and distress levels, and the determinants of family dissatisfaction and high-level distress. A multicenter questionnaire survey assessed 280 bereaved families of cancer patients who received sedation in 7 palliative care units in Japan. A total of 185 responses were analyzed (response rate, 73%). The families reported that 69% of the patients were considerably or very distressed before sedation. Fifty-five percent of the patients expressed an explicit wish for sedation, and 89% of families were clearly informed. Overall, 78% of the families were satisfied with the treatment, whereas 25% expressed a high level of emotional distress. The independent determinants of low levels of family satisfaction were: poor symptom palliation after sedation, insufficient information-giving, concerns that sedation might shorten the patient's life, and feelings that there might be other ways to achieve symptom relief. The independent determinants of high levels of family distress were: poor symptom palliation after sedation, feeling the burden of responsibility for the decision, feeling unprepared for changes in the patient's condition, feeling that the physicians and nurses were not sufficiently compassionate, and shorter interval to patient death. Palliative sedation therapy was principally performed to relieve severe suffering based on family and patient consent. Although the majority of families were comfortable with this practice, clinicians should minimize family distress by regular monitoring of patient distress and timely modification of sedation protocols, providing sufficient information, sharing the responsibility of the decision, facilitating grief, and providing emotional support.     

Gastric cancer: laparoscopic surgery and adjuvant chemotherapy

Demands for minimally invasive treatments for early gastric cancer and improved efficacy of recent chemotherapy regimens for advanced gastric cancer have led to considerable changes in the modality of treatment Laparoscopic gastrectomy (LG) with lymph node dissection is widely performed as minimally invasive surgery. The number of LGs is increasing each year. However, the results of a nationwide questionnaire survey performed by the Japanese Society for Endoscopic Surgery indicated that there are some postoperative complications associated with gastrointestinal anastomosis. In this paper, we describe our experiences with a unique intracorporeal surgical technique to prevent such complications. Although adjuvant chemotherapy is frequently administered to patients with advanced gastric cancer, no randomized controlled trial (RCT) has confirmed the prognostic significance of adjuvant chemotherapy, although some meta-analyses have. Since a number of published reports demonstrated the survival benefit of chemosensitivity test-guided chemotherapy after surgery for gastric cancer, we propose a protocol to perform a RCT to clarify whether chemosensitivity tests in adjuvant chemotherapy for gastric cancer have a significant impact.     

Olfactory groove schwannoma--case report

A 30-year-old man presented with a 2-year history of intermittent headache. No neurological deficit was detected. Computed tomography (CT) and magnetic resonance imaging showed a tumor with a diameter of 2.5 cm in the left anterior skull base associated with bone scalloping on three-dimensional CT. Angiography showed a hypovascular tumor. Craniotomy demonstrated a tumor in the region of the left olfactory groove attached to the anterior part of the cribriform plate. The histological diagnosis was schwannoma. Schwannoma arising from near the olfactory groove is rare, with only 13 other cases reported. The precise origin of these tumors is not well understood, but the tumor in this case probably arose from the fila olfactoria, because the olfactory bulb was involved in the tumor, whereas the olfactory tract remained intact.     

Ubiquitin-like polypeptide inhibits cAMP-induced p38 MAPK activation in Th2 cells

Ubi-L, an isoform of the monoclonal nonspecific suppressor factor (MNSF), is an 8.5-kDa ubiquitin-like polypeptide. Ubi-L exhibits an antigen-nonspecific immunosuppressive function on various target cells including murine T helper type 2 (Th2) clone, D10 cells. Ubi-L specifically binds to cell surface receptors on D10 cells. In this study, we observed that Ubi-L inhibited cAMP-induced IL-5 mRNA expression in D10 cells but not in thymoma cell line EL4. In addition, Ubi-L effectively inhibited cAMP-induced p38 MAPK activation in D10 cells. Ubi-L also showed inhibitory activity on IL-5 and IL-13 production by D10 cells stimulated with phorbol ester plus dibutyryl cAMP. Furthermore, Ubi-L inhibited IL-4 production in Th2 cells derived from primary CD4⁺ T cells.     

Imaging of acute pancreatitis--the role of US, CT and MRI

Imaging of the pancreas with US and CT plays a major role in the diagnosis and evaluations of patients with acute pancreatitis. In severe acute pancreatitis, dynamic CT is essential to assess the severity of the disease and evaluate the complications. MRI is comparable to CT in its capacity to provide precise information about the severity of acute pancreatitis. MRI has some advantages over CT in being free from ionizing radiation and lower toxity of gadolinium which is used for contrast medium intravenously. The disadvantages of MRI, however, include cost, longer exam duration, limited availability and the practical difficulties of scanning a patient with ICU equipment.     

Diffusion tensor imaging in frontal lobe epilepsy

We report a 13-year-old female with refractory frontal lobe epilepsy in whom diffusion tensor imaging was useful for exploring subtle cortical malformation. She had frequent simple partial seizures characterized by clonic movement of the right upper extremity. Conventional magnetic resonance imaging was not conclusive. A diffusion tensor imaging revealed an increased apparent diffusion coefficient and reduced anisotropy in the left frontal lobe. Positron emission tomography disclosed hypermetabolism in the adjacent area. We could identify the relatively thick cortex with an indistinct gray-white matter junction in a thin-slice T(1)-weighted image.     

Indomethacin, but not Helicobacter pylori, inhibits adaptive relaxation in isolated guinea-pig stomach

Nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (H. pylori) are major factors in gastritis and peptic ulcer However, the role of NSAIDs and H. pylori infection in dyspepsia remains unclear. Gastric adaptive relaxation may be related to the pathogenesis of functional dyspepsia because the response is often disturbed in dyspeptic patients. In this study, we investigated the effects of indomethacin or H. pylori water extracts on gastric adaptive relaxation. This experiment was performed using the modified method of Desai et al. Isolated guinea-pig stomach in an organ bath was monitored for intragastric pressure and volume. Adaptive relaxation was induced by gastric luminal distention. The effects of indomethacin and H. pylori on gastric relaxation were tested in this system. Indomethacin (> 1 x 10(-5) M) significantly inhibited adaptive relaxation. Indomethacin (> 3 x 10(-6) M) induced gastric relaxation in a dose-dependent fashion. However, aspirin at a concentration sufficient for cyclooxygenase (COX)-1 inhibition did not induce gastric relaxation. Preincubation with N-nitro-L-arginine methyl ester, a nitric oxide (NO)-synthase inhibitor, inhibited indomethacin-induced gastric relaxation. Adaptive relaxation was not affected by H. pylori water extracts. In conclusion, indomethacin inhibited adaptive relaxation via prior gastric relaxation. NO production, but not COX-1 inhibition, may be involved in this effect of indomethacin. H. pylori water extracts may not have direct effects on adaptive relaxation. Inhibition of adaptive relaxation may be one of the major mechanisms underlying NSAID-induced dyspepsia.     

Endoscopic internal biliary drainage in a child with malignant obstructive jaundice caused by neuroblastoma

We describe a 13-year-old girl who underwent insertion of a Flexima biliary stent for obstructive jaundice due to compression of the extrahepatic bile duct by an enlarged lymph node secondary to neuroblastoma. This novel endoscopic internal biliary drainage procedure was safe and effective even for a child, and improved her quality of life. We further review other treatment options available for malignant obstructive jaundice in children.     

Islet cell hyperplasia in transgenic mice overexpressing EAT/mcl-1, a bcl-2 related gene

EAT/mcl-1 (EAT), a bcl-2 related anti-apoptotic gene, is up-regulated at the early stage of differentiation of human embryonal carcinoma cells; cells which serve as a model for early embryogenesis. We generated transgenic mice for the human EAT gene driven by the EF1 alpha promoter in order to elucidate its functional role in vivo. Histologically, these mice exhibited hyperplasia of Langerhans islet cells; pancreatic cell regions composed of both insulin- and glucagon-producing cells. Furthermore, Bax and Bag-1 -- possible heterodimeric partners for EAT in the anti-apoptotic process -- were up-regulated in islets isolated from the EAT transgenic mice. The insulin tolerance test exhibited no significant difference between the EAT transgenic mice and non-transgenic mice, indicating that islet cell hyperplasia was not due to insulin resistance. In conclusion, EAT transgenic mice exhibit hyperplasia of pancreatic beta cells. EAT may inhibit apoptosis of beta cells, allowing these cells to circumvent the process of apoptosis until the adult stage.     

Various applications of direct PCR using blood samples

Samples of blood or other animal fluids contain a variety of substances that inhibit the polymerase chain reaction (PCR), meaning that isolation of DNA, involving multiple labor-intensive steps, is generally necessary prior to PCR. We have developed a novel reagent cocktail that effectively suppresses these inhibitory substances. Using this reagent cocktail, DNA from various targets can be efficiently amplified directly from various forms of blood samples without DNA isolation. 1. DNA sequences within the beta-globin gene could be amplified directly from human blood samples treated with various anticoagulants. Either fresh blood or blood samples stored frozen for up to 4 years could be used for PCR. 2. DNA sequences of up to 2056 bp within the beta-globin gene could be amplified directly from human blood samples. 3. Human chromosomal and mitochondrial DNA from different individuals could be amplified directly from blood samples. 4. Low titers of hepatitis B virus could be amplified directly from human blood samples. 5. DNA could be amplified directly from various target sequences using dried blood in a PCR tube or on a filter paper. 6. Transgenes could be detected directly in blood samples from transgenic mice.