Objective: The dispensing fee revision of April in 2016 made a review of the assessment of inquiries about prescriptions.  The requirement was added by articles that seemed to be pharmaceutically necessary, showing an increase of responsibility for pharmacists.  Based on this, we performed a discussion while collecting the cases of inquiries about prescriptions.
Method: Among the inquiries about prescriptions performed at Jinjo Pharmacy for 4 months starting from April in 2016, we selected 83 cases where a prescription was changed by the pharmacist’s recommendation, based on pharmaceutical information such as drug duplication or drug interaction and confirmation of leftover medicine.  Then, we compared them with the study of inquiries about prescriptions performed by the Japan Pharmaceutical Association in 2015.
Result/Consideration: Inquiries about dose were the leading content, followed by those about duplication with other drugs of same indications and appropriateness of dose considering the adjustment of number of days due to residual drug, which showed the importance of medicinal history and prescription records.  It is considered necessary to renew the contents of the prescription record properly, based on the information acquired, while at the same time changing the pharmaceutical history based on those records.  It is thought that an inquiry about prescriptions will be performed appropriately by making a judgment based on such information. In order to do that, updated knowledge about medicine and updated information about drugs is necessary.  In comparison of the two studies, both showed that the drug information on “safety” and “dose and dose regimen” accounted for a large part of inquiries.  Further consideration on them will be necessary.

Purpose: To investigate the characteristics of sudden abdominal condition change that occur in a palliative care unit, we evaluated the association between these conditions and family acceptance at time of death. Methods: We retrospectively investigated the medical records of 30 terminally ill cancer patients who died of sudden abdominal condition change in our unit between January 2010 and March 2013. We focused particularly on the course of sudden change, symptom relief, explanation of the condition, and family acceptance at time of death. Results: The average time from onset of sudden change in abdominal condition until death was 20.6 hours and the median was 13 hours. Of the 30 total cases, 23 occurred in less than 24 hours. Frequent symptoms during the sudden change were abdominal pain in 28 patients, decreased blood pressure in 21, lowering of consciousness in 12 and disturbed behavior/excitement in 10. Impending symptoms were observed in 18 patients. For patients with good acceptance by family at time of death (21 patients), symptom relief was significantly better, frequency of disturbed behavior/excitement was significantly less, and prior specific explanation was significantly frequent, compared to the poor acceptance group (9 patients). The good acceptance group tended to be have a longer hospital stay, as well as longer time between sudden change and death. Conclusions: Death by sudden abdominal condition change came within 24 hours in a majority of cases. We consider that prior detailed explanation and improving symptom relief helps improve family acceptance.

Delayed hemothorax following blunt chest trauma is classified as a late presentation of hemothorax after a nearly normal chest X-ray on admission. Here, we present a case of delayed hemothorax 5 days after blunt chest trauma with ribs and sternal fracture.

Purpose: We evaluated the significance of support for leaving the palliative care unit temporarily in end-stage terminally ill cancer patients. Methods: We retrospectively investigated the medical records of 27 terminally ill cancer patients who died within 15 days after leaving our palliative care unit temporarily, between January 2011 and December 2012, and distributed a questionnaire to their bereaved family. Results: The age of the patients ranged from 29 to 91 years. Ten patients left the unit without stay and 17 left overnight. The destination of 24 patients was their home, while three had other destinations. For 11 patients, the main purpose of leaving the unit was to finish business, and for 9, was to see their houses once again. After returning to the hospital, the comments of 15 patients were affirmative, and those of 6 were negative. Questionnaire responses were obtained from 18 persons. Families reported anxiety regarding and difficulty with adaptation to the sudden change when the patients left the unit, apparatus support, patient transfer, and patient care. Conclusions: It was useful for the terminally ill cancer patients and their families to receive support when leaving the palliative care unit temporarily. Strategies to cope with the sudden change at the time of leaving the unit could help families feel reassured and secure.

Objective: For safe use of drugs, it is indispensable to carry out proper and continuous risk management throughout preclinical to post-marketing phases.  In Japan, denosumab, a novel anti-RANKL antibody for treatment of bone metastasis, was approved in April 2012.  Since beginning of clinical use, severe hypocalcemia has been reported as adverse drug reactions.  In this study, the role of pharmacists in minimization of risks of newly introduced drugs was examined using denosumab as an example.
Methods: Firstly, the description on prevention of hypocalcemia in approval review report and different versions of drug package inserts of denosumab were compared.  Secondly, the differences in ratio of hypocalcemia in patients using denosumab with or without concomitant use of Ca and vitamin D preparations in Kobe City Medical Center General Hospital between April 2012 and July 2013 were examined.
Results: During the few months after beginning of clinical use of denosumab, many cases on the onset of severe hypocalcemia induced by denosumab had been reported.  Therefore, drug package insert was revised to enhance and recommend Ca and vitamin D supplementation.  Before the in-house enforcement in our hospital, of 26 patients, 6 patients were administered with denosumab without Ca and vitamin D preparations and 2 of them developed hypocalcemia over Grade 3.  After the in-house enforcement, no significant changed in serum Ca level in the 20 patients with Ca and vitamin D preparations were observed.
Discussion: Severe side effects can be avoided if hospital pharmacists take appropriate measures based on rational evaluation of proper information.
Conclusions: For risk minimization, pharmacists must evaluate and manage the risks of newly introduced drugs.

Purpose: To investigate the indications for use of the Japanese version of the Liverpool Care Pathway (LCP), we evaluated the conditions of patients using and those not using the LCP. Methods: We retrospectively investigated the medical records of 71 LCP patients and 60 non－LCP patients who died in our palliative care unit between March and December 2013. Results: There was no significant difference in patients’ background between the LCP and non－LCP groups. For patients in the non－LCP group, sudden changes in condition were significantly more frequent and deep continuous sedation was used significantly less than in the LCP group. In the LCP group, the average duration on the LCP was 4.0 days, and the beginning criterion was met by three－point or more of all the patients. The initial assessment was achieved except for one case. In the non－LCP group, reasons for not using the LCP were a sudden change in condition (35 patients), a rapid change in medical condition (14), and a risk of falling (4). Conclusions: The LCP met the beginning criterion and was started at suitable time in the LCP group. The LCP is not useful for all patients; it cannot be used for a patient with sudden or rapid changes in condition, or at a risk of falling.

A typical feature of mid-ventricular obstructive hypertrophic cardiomyopathy (MVO-HCM), is obvious hypertrophy of the mid-ventricular muscle and ventricle with transformation into the shape of an hourglass. We report a 60-year-old woman who had been given a diagnosis of apical type hypertrophic cardiomyopathy 12 years previously, but it changed to MVO-HCM with apical left ventricular aneurysm. We considered the impending rupture of the aneurysm because its wall was thin and pericardial effusion was detected by UCG (ultrasonic cardiograph). Urgent surgery was performed consisting of ventricular aneurysmectomy and patch reconstruction. After the surgery, a pseudoaneurysm was found in cardiac apex, so we performed surgery again. A residual shunt in the trabeculation caused the pseudoaneurysm, but its origin was not clear. She has been fine for 18 months without complications such as recurrence of aneurysm, ventricular arrhythmia or left ventricular dysfunction since the last surgery.

Between January 1994 and October 2004, 87 patients underwent emergency thoracic aortic surgery. Of these, 11 patients were more than 80 years old (O-group) and 76 were less than 80 years old (Y-group). A total of 58 patients (6 in O-group and 52 in Y-group) were treated for acute type-A aortic dissection, 5 (0 in O-group and 5 in Y-group) for acute type-B aortic dissection and 21 (4 in O-group and 17 in Y-group) for the involved rupture of a thoracic aortic aneurysm. The operative procedures consisted of the replacement of either the ascending, or the ascending and transverse aorta in 71 patients (8 in O-group and 63 in Y-group), and the replacement of the distal descending aorta in 15 patients (3 in O-group and 12 in Y-group). The operative mortality rates were 27.2% (3 patients) and 19.7% (15 patients) in the O- and Y-groups, respectively, with no significant difference between the groups. The rate of early complications, including circulatory failure, respiratory failure and cerebral infarction, did not statistically differ between the 2 groups. The overall 2-year survival rates of the patients who survived the operation were 83.3% in the O-group and 95.1% in the Y-group. Moreorer, 75% of the patients (6 of 8) who survived the surgery regained normal activities of daily life after the surgery, at a level similar to before the surgery. The present data indicates that emergency thoracic aortic surgery can be justified in selected in octogenarian patients.

We evaluated the association between respiratory symptoms and hydration volume during last 1 week of life in terminal cancer patients using retrospective study. The subjects were 138 terminally patients with malignancies. Patients were classified into two groups: the low hydration group (group L, n=85) who received 1,000 ml or less of artificial hydration per day in 1 week before death and high hydration group (group H, n=53) who received over 1,000 ml per day. We compared appearance of dyspnea and bronchial secretion on group L with group H. 64.1% of group H had dyspnea, and 52.8% had bronchial secretion. These fractions are significantly higher than group L (32.9%, 15.3%). In the results of multiple regression analysis, lung involvement (odds ratio: 3.55), hydration over 1,000 ml per day (3.54), and administration of opioid (0.40) were significantly related dyspnea. Lung involvement (7.29), hydration over 1,000 ml per day (4.43), and oral intake (0.31) were significantly related bronchial secretion. Our results provide preliminary evidence that excessive artificial hydration therapies influence the respiratory symptoms in terminal cancer patients. 1,000 ml of hydration may be used as a rough indication in terminal stage.

Purpose：We evaluated that the current state from which a palliative care unit receives emergency admission of cancer patients at home. Methods：We retrospectively investigated the medical records of 393 cancer patients who hospitalized in our unit between January 2013 and December 2014. The patients were shared with a group of two, schedule admission (schedule group) and emergency admission (emergency group), and it was compared with a result on discharge and with a hospitalization period. We investigated admission process, the date and time of admission, and reason for admission in emergency group. Results：The number of patients was 224 of schedule group and 169 of emergency group. The mortality rates were 81% in schedule group and 78% in emergency group (not significant). An emergency group for an average of 24.3 days was shorter for 9 days than schedule groups in a hospitalization period of dead leaving patients (p<0.05). In emergency group, admission process included 128 completed-interviews with the hospitalization, 11 incompleted-interviews before admission and 30 first visits, and 129 patients (76％) admitted within the weekday daytime. Many patients had a complaint of severe pain, appetite loss and oral absorption difficulty, and so much. Conclusions：An emergency group admitted the various processes and the much symptom. There were a lot of cases of early hospital death, but also admitted return at home, and our unit played the role of emergency admission.