4. Case study ??????

1
?????????? ?????

• ??????????
• ??????
• ?? ???

2
?????????????

• 1. ?????
• 2. ?????
• 3. ??
• 4. Case study ??????

3
?????????????

• 1. ?????
• 2. ?????
• 3. ??
• 4. Case study ??????

4
1.???????????
Q1 ????????????????????????
??
Grond S1) 1994 ??????????? 1635????? 27 ?? 20 ??
Morita T2) 1999 ???????? 150200? ????? 29??? 48 ????

1. Grond S J Pain Symptom Manage. 9372-382, 1994
2. Morita T J Pain Symptom Manage 18338-346,1999

5
Q2 ???????????????????????
???????? Nausea??,?? ???????????????
Vomiting?? ???????,?????????
??? ???????
6
Q3 ??????,????????????
?? ???? 1???????? ?? 10???? ?? ??
1???????(??????????????) (?? ??
1???????1???????????,??????????????????
????????,2,3????????????????1????????????
? JCOG ?????????? v3.0??????) ? ???mL
??(??,??) ????????(??)?
?(????)???(???) ???????????????? STAS 0-1
??????? 2 ??????????????????
3lt ???????
STAS ?????? 2.??????????????????????????? ???(
) 0 ?? 1 ?????????????????????????????
????????????????????????????????? 2
??????????????????????????????????????????????????
?? 3 ???????????????????????????????????????????
4 ????????????????????????????????
7
Q4 ??????,????????
?????
??,?????????
???????
???????
???????
?2??
8
??????????????
????
????
H1
Achm
CTZ ????????
VC ????
5HT3
D2
5HT2
H1
Achm
????
?? (??,??,??????)
?????
Achm
D2
5HT3
?????
?
?
CTZchemoreceptor trigger zone VCvomiting center
(Oxford Textbook of Palliative Medicine 3rd
2004????)
9
?1 ???????(???????)
??????? ?????? ?????
????
????
????
H1
Achm
????
CTZ ????????
VC ????
5HT3
D2
5HT2
Achm
H1
?????
????
?? (??,??,??????)
?????
5HT3
?????
?
?
10
?2 ???????(???????early emesis???)
???? (????????)
????
????
H1
Achm
CTZ ????????
VC ????
????? ???? ?????
5HT3
D2
5HT2
Achm
H1
????
?? (??,??,??????)
?????
5HT3
?????
?
?
11
?3 ????????????(??????????)
????
????
H1
Achm
CTZ ????????
VC ????
5HT3
D2
5HT2
Achm
H1
????
?? (??,??,??????)
?????? ?????
?????
D2
Achm
5HT3
?????
?
?
???????
?? (????)
??
12
?4 ?????????????
????????
????
????
H1
Achm
CTZ ????????
VC ????
5HT3
D2
5HT2
?????,????????? (??????????)
Achm
H1
????
?? (??,??,??????)
?????
5HT3
?????
?
?
13
?5 ????????(?????)
???? ????? ??????
???????
???
???
??????? ?????? ?????
???????????
????
????
H1
Achm
CTZ ????????
VC ????
5HT3
D2
5HT2
Achm
H1
??,?????
????
?? (??,??,??????)
?????
5HT3
?????
?
?
14
Q5 ?????????????
?????
??????,????????
?????
?????
???????? ?????????
???????? ???CT,MRI ???? ?????? ??? ??? ??
15
Q6 ?????????,????????????????
??
????????? ?? ?????? ?? ??? ???? ???? STAS
?????
??,?????study?? ???????????????????????????(?????
?) ???????????
??,???????? ???????
???
???????????? 1)????????????? 2)??????????? 3)???
????????? ??
16
Q7 ?????????????????
???
???
D2
?????
D2
D2
Achm
H1
Achm
?????? ?????
?????? ????? ????? ?????
???????? ???????,?????(???????)
????(?????????) ?????,??????(????????)
5HT3
5HT3
D2
H1
Achm
????? ???? ????? ??? ???? ?????
????? ????? ????
?????(????????) ??????(?????)
??????? ?????,?????? ?????????
H1
H1
Achm
????,????(??????)
??? ?????????? ???????????
17
Q8 ????????????evidence??
?????????RCTs
Author Sample Stydy design Regime Findings
1 Hardy J, 2002 92 ?????????? RCT ???? 24mg/? vs??????30mg/? vs placebo ??,????? 17,48 36,52 23,33 3??????
2 Mystakidou K, 1998 280 ?? ??,?????,?????,??,????,??? RCT ?????? 40mg/? ????? (????? 2mg/?) vs ?????????? vs ???? 5mg?? 7?????? ?????? ???? 78.9 gt?????????? 33.3 gt??????????? 23.6 ??????????????
3 Bruera E, 2000 26 ?????? RCT ?????? 80mg/? (???,?????) vs placebo ??????gtplacebo 17 12 mm vs 12 10 mm VAS???????
Ondansetron ???? Tropisetron ???? Metoclopramide
?????? Chlorpromazine ?????,??????

1. Hardy J Support Care Cancer 10231-236,2002
2. Mystakidou K Cancer 831214-1223,1998
3. Bruera E J Pain Symptom Manage 19427-435,2000

18
Evidence???trial?????,?????????????
Author Sample Study design Regime Findings
1 Bentley A, 2001 (PalliatMed 15247-253) 40 35 ?????,????? 30 ??,????? Prospec-tive audit ??(7????)?????????????????? (?? ?????,??????,?????,?????,?????,?????,???????) ??(score 1 best-5 worst) 82(28/34)??? ??(score 1best-5 worst) 84(26/31)???
2 Wilson J, 2002 (J Palliat Care 1884-91) 48 ????? open ?????? 80-160mg/? (???,?????) ????????? ?????? Not 27,Slightly 7 Moderately 29 Moderately to Highly 2 Highly 33
3 Bruera E, 1996 (J Pain Symptom Manage 11147-153) 100 ??100? Retrospective cohort ??????60mg-120mg/? ????? 0-20mg/? ?????3?? Step 4????????????????4???ladder ??,??(score 0 best-4 worst) 3.6,3.5 (n89 step 1) 3.1,3.3 (n12 step 2) 2.7,3.3 (n13 step 3) 3.3,2.6 (n25 step 4) 98????
4 Passik SD, 2002 (J Pain Symptom Manage 23526-532) 15 ???????? open ????? 0-10mg/? ??(score 0 best-4 worst) Score 0 1 2 3 4 0mg 0 3 2 5 4 5mg 8 6 0 1 0 10mg 10 2 1 1 0 (??)
19
?????????????

• 1. ?????
• 2. ?????
• 3. ??
• 4. Case study ??????

20
Q1 ????????????????????
????,?????????????????????
?? 1.???? ????? ??????? (??,??,??,?????)
?????? 2.?? ?????? ????
21
Q2 ?????????????????
???????,?????
?????(??,?,????) ???,??,???????????? ????
??????????? ????????? ?????(??,??)
??,??????? ???? ?????
22
Q3 ???????????????????
(Oxford Textbook of Palliative Medicine 3rd
2004????)
23
Q4 ??????????
?????
????? ???? PEG PTEG
?????
?????
?????
??????
???? ?????
???????
?????
??????
24
Q5 ?????????,??,???????????????
?????? ?? ????,??? ?? ????????? ?? ???????
???????
?,???????? ?? ???,????,???? ?? ???????????? ??
PEG (?????????????) PTEG
???????? (???????) ?? ????(short tube,NG
tube)
??,?????? ?? ????,?????? ?? ???????
????? ?????? ?? ???????? ???????
(???????) ?? ???? ?????
????????????,???????????????????
25
Q6 ?????????evidence??
????????????RCTs(steroid???)
Author Sample Stydy design Regime Findings
1 Hardy J, 1998 39 ????????(28?????????????????) RCT ????? 16mg 5?? vs placebo 5?? (cross over) ????????? ????? 13/21 62 Placebo 8/14 57 ??????????
2 Laval G, 2000 52 ???????????(28??????????????) RCT ??????? 40mg or ??????? 240mg vs placebo ????????? ?????? (40?) ????? 19/28 68 Placebo 4/12 33.5 ???(52?) (?????? 12????) ????? 22/37 59 Placebo 5/15 33.5 ????? ???????????????
3 Feuer DJ, 2003 Cochrane database,Review ???? NNT6 (???????1????????????????6???????)

1. Hardy J Palliat Med 12437-442,1998
2. Laval G Palliat Med 143-10,2000
3. Feuer DJ Cochrane database of systematic
   reviews,2003

Dexamethasone ????? Methylprednisolone ???????
26
??????????????RCTs
Author Sample Stydy design Regime Findings
1 Mercadante S, 2000 18 ???????????, ?????,?????? RCT ??????? 0.3mg vs ????? 60mg ?????48????? ??(??? 0,1,2,3) ??????? 1.5?0.4 ????? 2?1.7 ??(episode) ??????? 5.5?0.4 ????? 5.3?2.8 ???????gt?????
2 Mystakidou K, 2002 68 ??????????? RCT ??????? 0.6-0.8mg ( ???????? 15-25mg) Vs ????? 60-80mg (???????? 15-25mg) ?????,3???? ?? ??????? -93.4 ????? -86.2 ?? ??????? -82.1 ????? -67 ???????gt?????

1. Mercadante S Support Care Cancer 8188-191,2000
2. Mystakidou K Anticancer Res 221187-1192,2002

Octreotide ??????? Hysoscine butylbromide ?????
27
?????????????

• 1. ?????
• 2. ?????
• 3. ??
• 4. Case study ??????

28
Q1 ???????????
??
?????
????? ??????????
????? ???? ??? ??
??
??????? ?????? ???????
????????
????
????????
??? ???????? ??
???? ?????? ???
29
Q2 ?????????????
?? ???? ????(????) ????????????????
???????????
30
Q3 ???????????
?????
??
????
???????????
??(??)
??????????? ????
31
Q4 ????????????
1.?????????
3.???????
???????? ?????? ???
??????,????????? ???????
2.???????????
4.??
???????? ???? ??? ??
????,????? ?????? ?????,?????
32
?????????????

• 1. ?????
• 2. ?????
• 3. ??
• 4. Case study ??????

33
??1??????????????????????
????????????? ?????????????? ???????????? ???????
????
34
??1 ANSWER
????????????? ?????(????????)?????????
????????????????? ???????(????????)
????????? ????????????????????????????
??????(?????????????????????)????? ???
????????? ????????? ???(??????????????)?????
????? ????? ???????
????????????? ??????????????
35
??2?????????????????????????????????????
?????? ?????????????????? ???????? ???????????????
???
36
??2Answer
???????? ??????????????????????
??????????????????????? ????????
??????????????????????????? ?????????????!!
???????????????????? ????????????????????????
??????? ??????? (????????????????????)
????? 1???????????????????
37
??3??????????????????
??????NG???????????? ?????????????????? ??????????
??
38
??3 Answer
??NG???????????????????? ?????????????????????
??????????????????????????? ????????????????????
?????????? ????NG?????????????????????????
???????????????????? ?????????????????? ???????
???????? ?????????????????????????????
39
??4??????????
NG????????????? ???????????????? ????????
40
??4 Answer
????????? ???(?????????)
???????(?????????) ??????? ???????????????????(
E-8??)???????? ??????????????????????
(????????????????????????????) ?PEG?PTEG?????????
?? ??????????????????????? (???????????????????
)
41
??5????????????????
??????NG???????????? ?????????????? ?????????????
42
??5 Answer

???????????? ??????????????????????????
????????????????????????? ???????????????????????
???? ????????????????????????????????????????????
??????????? ??????????????????????????
??????????? ???????????????????? ??????????????
??? ????????????????????????????????????????
43
??6???????????????
???????????? ????????????? ????????NG?????????????
???????NG???????????????
44
??6 Answer
????????????????????? ??????????????????????????
????? ????????????????????????(?????)???
???????????????????????? ??????????????????????
? ?????? ???????????????????
???????????(??????????????????????)
????????????????????????? ?????????????????????
????????? ????????????????????
NG??????????????????????????????
?????????????????????????????? ?
???????????????????????????????
?????????????????????????? E.g.,
???1?????????12??????????
45
??7????????????????
???????????????????????? ???????? ????????
46
??7 Answer
???????????? ?????????(???? ??????? ?????)
????(???)??????(??????????)??? ??????
??????????????????????? ???????????
?????????????? ??????????? ??????????????? ??
?????????????? ?????????????????????
?????????????????????EPA??
47
??8??????????????????????????
?????????????????????? ??????????? ???????????????
?????????
48
??8 Answer
?????????????????????????? ????????????????????
??????? ?????????????(??????????) ?????????????
???????????????????????? ????????????????
??????????? ?????????????????????????????
??????????????????????????????
(?????????????????????)
49
??9?????????????
??????????????????? ????????????????
50
??9 Answer
?????????????????????????? ????????????????????
??????? ?????? ??????????????? ?
??????????????????????????? ????????????????????
????? ???????????????????????
???????????????????
51
??10????????????????????????
NG??????????????????? ???????????? NG?????????????
?????????? ????????????????????
52
??10 Answer
?NG????????????????????? ???????
???????????? ??????? ?????
?? ??????????????????? ?????????? ?????????????
??????????????? E.g., ?????????? ????????????(?
?????????????????)