The patient was a woman in her 70s, who had been diagnosed as having a malignant fibrous histiocytoma in the right axilla with invasion to the intrathoracic space at a local hospital. The growth of cytokine-producing tumor was suspected, and thrombocytopenia caused by bleeding and jaundice by blood transfusion were disclosed. When she was admitted to our palliative care unit, the platelet count was 19,000/μl and total bilirubin was 6.4mg/dl. Furthermore, several predictive fools showed the prognosis for survival was poor. After transferal to our hospital, the patient was treated mainly with medication. No blood transfusion was given. In the clinical course, the platelet count and total bilirubin level were restored to normalcy. The patient lived on for another five months or over. The contributing factors, in prolonging her life longer than predicted were probably as follows; (1) spontaneous recovery of thrombocytopenia without bleeding, (2) improvement of jaundice caused by the blood transfusion, and (3) foods taken orally even in small amounts. There are patients whose prognosis varies substantially in the fields of the palliative care. It is important to work out proper medical treatment and care plans according to symptoms and the status of patients.

Introduction: It is difficult in the treatment for the patients with refractory pruritus by conventional oral or external medication. Case report: A 72-year-old woman with pancreatic metastasis of primary lung cancer, who was treated by control-release oxycodone for cancer pain and endoscopic biliary drainage for obstructive jaundice. Although external medication and oral anti-allergic agents (mirtazapine and herbal medicine) were administered for pruritus, there was no improvement. The patient was diagnosed with refractory pruritus and pregabalin was administered. After the beginning of low dose, increase of dosage provided improvement at the third day of the administration. Finally, numerical rating scale improved from 8/10 in previous treatment to 0-1/10 in following treatment, and the symptom was relieved. Discussion: A few previous research of effectiveness on pregabalin for pruritus have been reported from abroad. The improvement for refractory pruritus was provided by pregabalin. Conclusion: We conclude that pregabalin is a one of the options for effective treatment for refractory pruritus.

　　Purpose: To elucidate the degree of self-conctribution of each member of a palliative care team and the palliative effect patients. Patients and Methods:The degree of self-contribution to intervened patients and the degree of improvements in the symptoms items listed in a Japanese version of the Support Team Assessment Schedule (STAS-J) were examined prospectively. Results: The degree of self-contribution was often higher in doctors, nurses, clinical psychotherapists and pharmacists, and lower in nutritionists. It was related to age, gender, site of primary disease and the duration of intervention. The symptom items which showed improvement were such items as pain, nausea, vomiting, appetite loss and insomnia, but delirium and depression worsened. The degree of self-contribution and the degree of improvement in symptom were correlated in seven items in the case of pharmacists but only in one in the case of other professionals. Discussion: The degree of self-conribution varied and was not always high even after the intervention of the care team. It was considered that the fact that the number of related items was larger in pharmacists than in any other professionals was probably because the pharmacists could assess the symptoms and propose drugs from an objective point of view, although character might be mostly involved. Conslusion: It is to be hoped that every one engaged in palliative care will do what is one’s forte and apply each one’s individuality properly in the future.

　　The first patient was a 33-year-old man with a history of fatty liver disease. Dynamic computerized tomography of a lesion in liver segment IV showed faint staining in the arterial phase and high signal intensity in the portal venous and equilibrium phases. The second patient was a 57-year-old woman also with a history of fatty liver disease. Magnetic resonance imaging (MRI) of a lesion in segment II in T1 out of phase revealed geographic morphology and high signal intensity. Furthermore, Gd-EOB-DTPA-enhanced MRI showed accumulation in the lesion in the hepatobiliary phase. In both cases, an aberrant left gastric vein and focal fat sparing area was diagnosed. Venous inflow to the liver other than via the portal vein may cause fatty degeneration of liver parenchymal cells or focal fat sparing due to imbalanced intrahepatic blood flow. In the present cases, imaging revealed a focal fat sparing area with an aberrant left gastric vein. Focal fat sparing area with aberrant inflow vessel identified in the background of fatty liver does not require biopsy or surgery. Therefore, further detailed evaluation of such images is warranted.

  The case was a man in his 80s, who had been in home care with primary hepatocellular carcinoma before hospitalization. He suffered nausea and appetite loss. However, hypercalcemia in laboratory data, brain metastasis on head CT and MRI, and intestinal obstruction or dilatation on abdominal CT, were not revealed. Upper gastrointestinal endoscopy detected no mechanical abnormality after admission to hospital and medical treatment with 3.75mg/day of mirtazapine was started. The dietary intake increased on the following day of the administration and nausea and appetite loss were improved, so the patient was discharged. In conclusion, low-dose mirtazapine was considered to be one of the effective therapeutic agents for nausea from unknown causes in cancer patients.

　　Objective: To elucidate the appearance of skin moisturization (cold and clammy skin) indying period and related factors. Methods: Patients were observed prospectively with skin moisturization using the clinical pathway for end-of-life care (Liverpool Care Pathway Japanese version [LCP]) by nurses in the palliative care unit. Results: Of 213 patients placed on LCP, 48 (22.5%) indicated skin moisturization, which was observed mostly in summer and in the morning. It appeared 45.8 hours before death on the average. By multivariate analysis, the administration of non-steroidal anti-inflammatory drugs (NSAIDs) was an independent related factor. Conclusions: Compared to our previous retrospective study, the appearance of skin moisturization was higher in frequency and earlier in the dying period, and the administration of NSAIDs was an independent related factor.

  One patient was intervened by our palliative care team (PCT) to relieve neuropathic pain due to postoperative recurrence of rectal cancer. The dosage controlled-release oxycodone was increased, analgesic adjuvant drugs were changed and the administration of betamethasone were started. Furthermore, the number of times the patient took controlled-release oxycodone increased two to three times a day. These changes in medication resulted in relief of symptoms. Cetuximab therapy was given twice during the course. The other patient was intervened by the PCT for right upper limb pain and dyspnea due to postoperative recurrence of breast cancer. Morphine sulfate hydrate and analgesic adjuvant were additionally given. As pain increased three days after the administeration of transdermal fentanyl patches, the patches were changed every other day, instead of every three days. FEC100 therapy was given twice during the course. In the present two cases, the PCT was intervened with great zeal and rapid relief of symptoms resulted. In the meantime chemotherapy proceeded uneventfully. We thought that trust of the chief doctor in the PCT was most important for effective intervention.

  The patient was a woman in her 80s, who was referred to the palliative care team in our hospital for pain due to bone metastases from lung cancer. Although gabapentin and ifenprodil tartrate were administrated in addition to opioids and loxoprofen sodium, and the dose of opioids was increased, pain was not relieved remarkably. A switch from gabapentin to pregabalin brought remarkable pain relief. Before the internal use of pregabalin, the patient was often seen lyiing in bed because of pain. However, by pregabalin, she began to walk, pushing her wheelchair and smile often. Her ability to perform the basic activities of daily living was improved. The switch from gabapentin to pregabalin was one effective option when an analgesic adjuvant for cancer pain was chosen.

We experienced two cases of postherpetic neuralgia (PHN) improved with Kampo medicines that include uzu (i.e. uzu-zai).The pain from PHN was improved via the administration of an uzu-zai in these 2 cases, worsened by its discontinuation, and improved again by its re-introduction.Case 1 : A 76-year-old male suffering from PHN of the right L 2-3 area was administered uzukeishito and obtained pain reduction. After 12 months, his prescription was changed from uzukeishito to keishikaryoju-tsubuto. Then, after only 2 days his pain worsened again. Uzukeishito treatment was re-instated, and he again obtained pain reduction. Case 2 : An 82-year-old male suffering from PHN of the right C 4-5 area was given uzuto and obtained pain relief. After 3 months his prescription was changed from uzuto to keishikajutsubuto. Then, after only1week his pain worsened again. Uzuto was then re-introduced, and pain reduction was achieved again. These two cases led to two suggestions. First, that the uzu-zais were very effective against the PHN pain. Second, that this effect of an uzu-zai against PHN pain might be a symptomatic rather than a radical treatment.These two cases highlight the fact that the use of an uzu-zai was instrumental in reducing PHN-associated pain, but further studies will be needed to determine a dosage protocol, including when and at what pace uzu-zais might be reduced/discontinued.

Pure autonomic failure (PAF) is a degenerative disorder with diverse autonomic nervous symptoms, but without somatic nervous symptoms. We encountered a patient with PAF who was successfully treated with keishikashakuyakuto. A 61-year-old man complained of diarrhea, abdominal pain, dysuria and orthostatic hypotension. PAF was strongly suspected, based on a low level of plasma noradrenalin at rest and a finding of severe diffuse sympathetic nerve injury on ¹²³I MIBG myocardial scintigraphy. Various Kampo formulas were not effective, or could not be administered continually. Urinary retention was treated with self-catheterization. After the extract of keishikashakuyakuto was administered, his complaints of diarrhea and abdominal pain gradually decreased, and he was able to eat various kinds of food. His daily living activities improved.Moreover, he could urinate by himself, so the self-catheterization was stopped. Five years later, the diagnosis of PAF was clinically confirmed, but his daily living activities did not deteriorate. This suggests that keishikashakuyakuto can be effective for diseases with diverse autonomic nervous symptoms, such as the present case.