Purpose：To explore a methodology for evaluating end-of-life （EOL） cancer care using diagnosis procedure combination （DPC） administrative data. Methods： We investigated care provided to inpatients whose deaths were attributed to cancer and occurred between August 2010 and December 2012. We measured the quality of palliative care by dividing the decedents into two groups： those who died in the palliative care unit （PCU） and those who died in the general wards（GW）. Results： A total of 311 inpatient deaths were identified as cancer deaths. Of these, 147 patients were included in the PCU group and 164 in the GW group. We calculated the DPC data as follows： the rates of chemotherapy administered within 30 days before death （PCU 0％, GW 27％） and within 14 days before death （PCU 0％, GW 10％）, admission to the intensive care unit （PCU 0％, GW 2％）, life-sustaining interventions （PCU 0％, GW 3％）, rehabilitation sessions （PCU 10％, GW 26％）, emergency admission （PCU 2％, GW 27％）, and antibiotics （PCU 32％, GW 28％）. In the PCU group, rates of chemotherapy and emergency admission were significantly lower（＜0.0001；＜0.0001, respectively）, and rehabilitation sessions were significantly higher （p＝0.0002） than in the GW group. Conclusion： EOL care in a university hospital can be easily investigated using DPC data. Some limitations are the single-site study design, the health insurance system, and secondary use of administrative data. However, this methodology may be adapted to investigate the entire Japanese claim database and to evaluate EOL cancer care.

Purpose：This study investigated the current state of medical care and home palliative care for terminally ill cancer patients in Japan. Methods：We conducted a retrospective questionnaire study of 352 cancer patients who received home palliative care from 6 specialized home care clinics and discontinued home care or died from January to June in 2012. Results：The questionnaire was answered by 290 patients〔165 men（57％）, mean age：72±13 years〕who started home palliative care after completing cancer treatment. Home visits from nurses were used by 238 patients（98％）and 95 patients（39％）used home care workers. Within a month before discontinuation of home care or death, 72 patients（30％）received fluid therapy and 127 patients（52％）received strong opioids. The outcome of home palliative care was death at home in 242 patients（83％）and discontinuation of home care in 48 patients（17％）. The reason for discontinuation was family physical and mental problems or physical problems of the patient. Conclusion：This study demonstrated the current state of home palliative care by specialized home care clinics.

Objectives:To determine the factors influencing death or the cessation of palliative care in home-based setting among patients with cancer. Methods:We included 352 terminally ill patients with cancer who received home-based palliative care from six specialized palliative care clinics. We reviewed the medical charts when patients died at home or chose to stop home care. Results:A total of 82％ of participants died at home, and 18％ chose to stop home care. Multiple logistic regression analysis revealed five independent factors that affected cessation of home-based palliative care:patient and informal caregiver preferences for the place of death not to be at home［odds ratio, 10.1（95％ Confidential interval, 2.5-40.9）and 51.9（11.9-226.6）, respectively］or uncertain preferences［5.0（1.3-19.4）, 10.8（2.3-50.5）］;anxiety and depression among informal caregiver［4.1（1.2-13.9）］;lower frequency of informal care［6.8（2.0-23.4）］;and history of admittance to hospital during home care［11.6（4.0-33.9）］. Conclusion:We revealed independent factors influencing death or the cessation of palliative care in home-based settings among patients with cancer. Our findings suggest the importance of providing support for decision making about the place of death and hospital admission, and psychosocial support for informal caregiver to ensure home death consistent with patient preference.

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STUDY DESIGN: Retrospective study. PURPOSE: We conducted a study to investigate the time course changes in bone metabolic markers after the administration of the anti-receptor activator of nuclear factor-kappa B ligand (RANKL) antibody and to assess drug compliance among osteoporotic patients. OVERVIEW OF LITERATURE: The anti-RANKL antibody is expected to provide an improvement in those with a bone metabolism disorder. However there are only a few clinical reports available on the effect of treatment. METHODS: We included 40 post-menopausal osteoporotic patients who received the anti-RANKL antibody. To determine the time course changes in the bone metabolic markers, we measured the serum tartrate-resistant acid phosphatase 5b (TRACP 5b; a bone resorption marker) and the serum N-terminal propeptide of type 1 collagen (P1NP; a bone formation marker) levels prior to and 1 month after administrating the anti-RANKL antibody. To evaluable drug compliance, we assessed the dropout rate during treatment and at 6 months after treatment. RESULTS: The average TRACP 5b level significantly decreased from 574.8 mU/dL before treatment to 153.2 mU/dL 1 month after treatment (p<0.05). There was no significant difference in the average P1NP level, which was 56.9 microG/L and 35.1 microG/L before and 1 month after treatment, respectively (p>0.05). As for drug compliance, we did not have any dropouts during the treatment or after 6 months (dropout rate: 0%). CONCLUSIONS: Our study suggests that anti-RANKL antibody treatment suppresses bone resorption and maintains bone formation.
Acid Phosphatase ; Bone Resorption ; Collagen Type I ; Compliance* ; Humans ; Metabolism ; Osteogenesis ; Osteoporosis* ; Patient Dropouts ; RANK Ligand ; Retrospective Studies

STUDY DESIGN: Retrospective cohort study. PURPOSE: To assess bone mineral density (BMD) and bone metabolism ≥27 years after surgery in female patients who underwent spinal fusion for adolescent idiopathic scoliosis (AIS) during adolescence and to determine their associations with physical performance. OVERVIEW OF LITERATURE: There are no studies investigating postsurgical BMD in middle-aged AIS patients. METHODS: This study included 23 patients who provided informed consent among 229 female patients with AIS who underwent spinal fusion from 1968 until 1988. Average age at the time of observation was 48.8 years. BMD was measured at the left femoral neck, and the levels of two bone metabolism markers–procollagen type 1 N-terminal propeptide (P1NP) and tartrate-resistant acid phosphatase 5b (TRACP-5b)–were measured from blood samples. Physical performance was measured using grip strength, sit-ups, sit-and-reach, side step, and standing long jump. RESULTS: Mean BMD was 0.784 g/cm2. According to the World Health Organization diagnostic criteria, one subject (4.3%) had osteoporosis, whereas nine subjects (39.1%) had osteopenia. In patients with osteoporosis or osteopenia, P1NP and TRACP-5b levels were high, and BMD loss was because of high metabolic turnover. All calculated standard scores for physical performance were lower in the study cohort than in healthy individuals. There was a positive correlation between BMD and the standard score for grip strength, whereas there were weak positive correlations between BMD and the standard scores for side step and standing long jump. CONCLUSIONS: In female AIS patients who underwent spinal fusion in adolescence, 4.3% and 39.1% had osteoporosis and osteopenia, respectively, ≥27 years after surgery. Exercise performance of these patients was poor compared with the national standards. In these patients, increased physical activity should be encouraged to prevent BMD loss in middle age.
Acid Phosphatase ; Adolescent* ; Bone Density* ; Bone Diseases, Metabolic ; Cohort Studies ; Female* ; Femur Neck ; Hand Strength ; Humans ; Informed Consent ; Metabolism ; Middle Aged ; Motor Activity ; Osteoporosis ; Retrospective Studies ; Scoliosis* ; Spinal Fusion ; World Health Organization

STUDY DESIGN: Experimental human study. PURPOSE: To determine whether angiopoietin-like protein 2 (ANGPTL2) is highly expressed in the hyperplastic facet joint (FJ) synovium and whether it activates interleukin-6 (IL-6) secretion in FJ synoviocytes. OVERVIEW OF LITERATURE: Mechanical stress-induced synovitis is partially, but significantly, responsible for degenerative and subsequently osteoarthritic changes in the FJ tissues in patients with lumbar spinal stenosis (LSS). However, the underlying molecular mechanism remains unclear. IL-6 is highly expressed in degenerative FJ synovial tissue and is responsible for local chronic inflammation. ANGPTL2, an inflammatory and mechanically induced mediator, promotes the expression of IL-6 in many cells. METHODS: FJ tissues were harvested from five patients who had undergone lumbar surgery. Immunohistochemistry for ANGPTL2, IL-6, and cell markers was performed in the FJ tissue samples. After cultured synoviocytes from the FJ tissues were subjected to mechanical stress, ANGPTL2 expression and secretion were measured quantitatively using real-time quantitative reverse-transcription–polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA), respectively. Following ANGPTL2 administration in the FJ synoviocytes, anti-nuclear factor-κB (NF-κB) activation was investigated using immunocytochemistry, and IL-6 expression and secretion were assayed quantitatively with or without NF-κB inhibitor. Moreover, we assessed whether ANGPTL2-induced IL-6 modulates leucocyte recruitment in the degenerative process by focusing on the monocyte chemoattractant protein-1 (MCP-1) expression. RESULTS: ANGPTL2 and IL-6 were highly expressed in the hyperplastic FJ synovium samples. ANGPTL2 was co-expressed in both, fibroblast-like and macrophage-like synoviocytes. Further, the expression and secretion of ANGPTL2 in the FJ synoviocytes increased in response to stimulation by mechanical stretching. ANGPTL2 protein promoted the nuclear translocation of NF-κB and induced IL-6 expression and secretion in the FJ synoviocytes. This effect was reversed following treatment with NF-κB inhibitor. Furthermore, ANGPTL2-induced IL-6 upregulated the MCP-1 expression in the FJ synoviocytes. CONCLUSIONS: Mechanical stress-induced ANGPTL2 promotes chronic inflammation in the FJ synovium by activating IL-6 secretion, leading to FJ degeneration and subsequent LSS.
Chemokine CCL2 ; Enzyme-Linked Immunosorbent Assay ; Humans ; Immunohistochemistry ; Inflammation ; Interleukin-6 ; Spinal Stenosis ; Stress, Mechanical ; Synovial Membrane ; Synovitis ; Zygapophyseal Joint

Objectives: This study aims to investigate the effects of romosozumab on bone mineral density (BMD) and bone metabolism. Methods: In this retrospective case series, romosozumab was administered to 5 premenopausal female patients with osteoporosis and anorexia nervosa with fragility fractures. BMD and bone turnover marker changes were investigated at 6 months and 1 year after administering romosozumab. Results: BMD increased and high-turnover bone metabolism decreased 6 months and 1 year after administering romosozumab. Conclusions Romosozumab is useful for treating osteoporosis in patients with anorexia nervosa.

STUDY DESIGN: Retrospective case series. PURPOSE: To examine the most effective duration of teriparatide use for spinal fusion in women with postmenopausal osteoporosis. OVERVIEW OF LITERATURE: We reported that daily subcutaneous injection of teriparatide (parathyroid hormone) significantly improved bone union after instrumented lumbar posterolateral fusion (PLF) in women with postmenopausal osteoporosis when compared with oral administration of bisphosphonate. However, the most effective duration of teriparatide use for spinal fusion has not been explored. METHODS: Forty-five women with osteoporosis diagnosed with degenerative spondylolisthesis from one of the three treatment groups were evaluated based on: short-duration treatment (average, 5.5 months; n=15; daily subcutaneous injection of 20 microg teriparatide), long-duration treatment (average, 13.0 months; n=15; daily subcutaneous injection of 20 microg teriparatide), and bisphosphonate treatment (average, 13.0 months; n=15; weekly oral administration of 17.5 mg risedronate). All patients underwent PLF with a local bone graft. Fusion rate and duration of bone union were evaluated 1.5 years after surgery. RESULTS: Bone union rate and average duration for bone union were 92% and 7.5 months in the long-duration treatment group, 80% and 8.5 months in the short-duration treatment group, and 70% and 10.0 months in the bisphosphonate treatment group, respectively. Results of bone union rate and average duration for bone union in the teriparatide treatment groups were significantly superior to those in the bisphosphonate treatment group (p<0.05); whereas, significantly superior results were observed in long-duration treatment group when compared with short-duration treatment group (p<0.05). CONCLUSIONS: Daily injection of teriparatide for bone union was more effective than oral administration of bisphosphonate. Furthermore, a longer period of teriparatide treatment for bone union was more effective than a shorter period of same treatment.
Administration, Oral ; Female ; Humans ; Injections, Subcutaneous ; Osteoporosis ; Osteoporosis, Postmenopausal ; Retrospective Studies ; Spinal Fusion ; Spondylolisthesis ; Teriparatide* ; Transplants

PURPOSE: The pathophysiology of discogenic low back pain is not fully understood. Tetrodotoxin-sensitive voltage-gated sodium (NaV) channels are associated with primary sensory nerve transmission, and the NaV1.7 channel has emerged as an analgesic target. Previously, we found increased NaV1.7 expression in dorsal root ganglion (DRG) neurons innervating injured discs. This study aimed to examine the effect of blocking NaV1.7 on sensory nerves after disc injury. MATERIALS AND METHODS: Rat DRG neurons innervating the L5/6 disc were labeled with Fluoro-Gold (FG) neurotracer. Twenty-four rats underwent intervertebral disc puncture (puncture group) and 12 rats underwent sham surgery (non-puncture group). The injury group was divided into a saline infusion group (puncture+saline group) and a NaV1.7 inhibition group, injected with anti-NaV1.7 antibody (puncture+anti-NaV1.7 group); n=12 per group. Seven and 14 days post-surgery, L1 to L6 DRGs were harvested and immunostained for calcitonin gene-related peptide (CGRP) (an inflammatory pain marker), and the proportion of CGRP-immunoreactive (IR) DRG neurons of all FG-positive neurons was evaluated. RESULTS: The ratio of CGRP-IR DRG neurons to total FG-labeled neurons in the puncture+saline group significantly increased at 7 and 14 days, compared with the non-puncture group, respectively (p<0.05). Application of anti-NaV1.7 into the disc significantly decreased the ratio of CGRP-IR DRG neurons to total FG-labeled neurons after disc puncture at 7 and 14 days (40% and 37%, respectively; p<0.05). CONCLUSION: NaV1.7 antibody suppressed CGRP expression in disc DRG neurons. Anti-NaV1.7 antibody is a potential therapeutic target for pain control in patients with lumbar disc degeneration.
Animals ; Antibodies ; Calcitonin Gene-Related Peptide/metabolism ; Disease Models, Animal ; Ganglia, Spinal/*metabolism ; Intervertebral Disc/*drug effects/*injuries ; Intervertebral Disc Degeneration/metabolism ; Low Back Pain/*physiopathology ; Lumbar Vertebrae/injuries ; Male ; NAV1.7 Voltage-Gated Sodium Channel/*metabolism ; Neurons/*metabolism ; Pain/metabolism ; Rats ; Rats, Sprague-Dawley ; Stilbamidines