Introduction: It is difficult to manage that pruritus complicated with jaundice, for invalidity of almost all antihistamines. Recently, effects of paroxetine for pruritus are reported, but the report to invalid cases of paroxetine is rare. We report a case treated effectively with mirtazapine for pruritus of the paroxetine invalid. Case report: A 56-years old woman was diagnosed cancer of head of pancreas and peritoneal dissemination.After stenting by a plastic stent for obstructive jaundice in previous hospital, she came to our hospital. But, her total bilirubin (T-bil) were very high (9.9 mg/dl), and she was suffering from systemic pruritus. The NRS (numerical rating scale) score for pruritus was 9-10. Though she was prescribed an antihistamine in previous hospital, it was invalid. We had changed it to paroxetine, but pruritus were protraction two weeks later. After changing it to mirtazapine, the pruritus became NRS 1 on the next day, and recurrence was not seen subsequently. Conclusion: For pruritus of the paroxetine invalid, mirtazapine is important as one of the choices.

Background: Although rectal tenesmus in patients with advanced cancer can have marked negative impact on quality of life, effective treatment has not yet been established. Case: A 71 -year-old man with an inoperable rectal cancer developed tenesmus 11 months after a colostomy. Tenesmus worsened over the following 3 months, and the patient suffered from involuntary straining every 5-15 minutes. After unsuccessful symptom control with radiotherapy to the primary lesion, we started oral amoxapine 25 mg that alleviated symptoms related to tenesmus. As the general condition deteriorated, however, oral intake became difficult. After the discontinuation of amoxapine, the tenesmus recurred even though intravenous administration of clomipramine was initiated. We started continuous infusion of intravenous lidocaine 200 mg/day which successfully relieved tenesmus. The dose of lidocaine was subsequently increased to 290 mg/day for worsening symptoms, which continued to control his distress caused by tenesmus until he died. Consideration/Conclusion: This is the first report that demonstrates the efficacy of oral amoxapine for rectal tenesmus with malignant tumor. After the discontinuation of amoxapine due to the inability of taking medications orally, symptoms remained under adequate control with infusional lidocaine until the patient died. Further studies are warranted to confirm our findings and to propose optimal use of medications in the management of rectal tenesmus.

Introduction: We experienced a case in which acetazolamide proved to be effective for the symptoms of increased intracranial pressure due to carcinomatous meningitis. Case: The patient was a male in his fifties who was diagnosed lung adenocarcinoma. He was suffered from headache and vomiting due to carcinomatous meningitis after his admission to our palliative care unit, so he was prescribed steroids and a glycerin infusion. But only morning headache remained, and we added acetazolamide 500 mg per day and his morning headache improved. Conclusion: This morning headache is thought to reflect exacerbation of raised intracranial pressure through nocturnal hypoventilation with a rise in PaCO2, so it was thought that acetazolamide decreased PaCO2 and relieved morning headache.

Background: The demand for palliative care in Japan has risen over recent years, and training of palliative care physicians is an important problem. However, little is known about unmet needs for education and training systems as well as career development among young physicians who wish to specialize in palliative care. Purpose: To explore unmet needs among palliative care physicians in training. Method: We held group discussions in a forum for physicians of postgraduate year≦15, and analyzed their opinion on topics such as "what are unmet needs?" using theme analysis. Results: Forty physicians participated. Theme analysis revealed the following unmet needs among young physicians; "securing of manpower", "securing of quality of training programs/education", "improvement of network", "removal of many barriers to keeping on a palliative care physician", and "establishment of career models for a specialist". Conclusions: We should discuss solutions for the unmet needs to secure more palliative care physicians.