4,520 research outputs found

    Palliative sedation in patients with advanced cancer followed at home: a prospective study.

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    Abstract CONTEXT: Home care programs in Italy. OBJECTIVES: The aim of this study was to assess a protocol for palliative sedation (PS) performed at home. METHODS: A total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam. RESULTS: A total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P=0.012). The principal reasons to start PS were agitated delirium (n=20) and dyspnea (n=4). Mean duration of PS was 42.2±30.4 hours, and the mean doses of midazolam were 23-58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively. CONCLUSION: This protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies

    Opioid switching in patients with advanced cancer followed at home. A retrospective analysis

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    Abstract CONTEXT: Opioid switching has been found to improve opioid responsiveness in different conditions. However, data on opioid switching performed at home are almost nonexistent, despite the fact that most patients are followed at home. OBJECTIVES: The aim of this retrospective survey was to determine frequency, indications, usefulness, and safety of opioid switching when treating advanced cancer-related pain in patients followed at home. METHODS: A retrospective review of data from patients with advanced cancer followed at home by three home care teams for a period of two years was performed. Patients who had their opioids switched were selected. Reasons for switching opioid doses and routes of administration and outcomes were collected. RESULTS: Two hundred one (17%) of 1141 patients receiving "strong" opioids were switched. The mean Karnofsky Performance Status score was 35.6, and the median survival was 30 days. The most frequent reason to switch was for convenience, and the most frequent switch was to parenteral morphine. In most patients, a better analgesic response was observed. Patients who were switched to parenteral morphine had a shorter survival in comparison with other opioid sequences (P<0.0005). After switching, opioid doses were increased by 23% and 41%, after a week and at time of death, respectively. CONCLUSION: Opioid switching was useful for most patients in the home environment, at least in less complex circumstances, when done by experienced home care teams. Prospective studies are needed to provide information about the decision to admit to hospital for this purpose and the predictive factors that may relatively contraindicate transportation to a facility in severely ill patients

    Orphan symptoms in advanced cancer patients followed at home.

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    Abstract Orphan symptoms are rarely assessed, particularly at home. The aim of this multicenter prospective study was to assess the prevalence of these symptoms and eventual factors possibly associated in advanced cancer patients at admission of a home care program. A prospective study was performed at three home care programs in Italy. Patients' data were collected, including age, sex, diagnosis, and Karnofsky status. Possible contributing factors were analyzed; preexisting neurological diseases, cerebral metastases, hyperthermia, diabetes, a state of dehydration clinically evident and/or oliguria, possible biochemical parameters when available, data regarding recent chemotherapy, opioids and doses, use of neuroleptics, benzodiazepine or anticonvulsants, corticosteroids, anti-inflammatory, and antibiotics were collected. Myoclonus, hiccup, sweating, pruritus, and tenesmus, either rectal or vesical, were assessed, according to a preliminary definition, at time of home care program admission. Three hundred sixty-two patients were surveyed at the three home care programs. Globally, 48 patients presented one or more orphan symptoms in the period taken into consideration, and 7 patients presented more than 1 symptom. One patient presented occasional and diffuse myoclonus. Nineteen patients presented sweating, 13 patients presented pruritus, and 14 patients presented hiccup. Finally, nine patients presented rectal or vesical tenesmus. There was a significant correlation between sweating and transdermal fentanyl use (P = 0.044), fever (P = 0.001), hiccup (P < 0.0005), and vesical tenesmus (P = 0.028). Pruritus was not associated to any factor. Hiccup was associated with gender (males, P = 0.006) and sweating (P < 0.0005). Vesical tenesmus was associated with fever (P = 0.019) and sweating (P = 0.028). Although the symptoms examined have a low prevalence in advanced cancer patients admitted to home care, the distress for patients may be high and deserve further analyses. Given the low prevalence of these symptoms, large studies are needed to find possible associated factors

    Palliative sedation in advanced cancer patients followed at home: a retrospective analysis.

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    Abstract CONTEXT: Data regarding palliative sedation at home in dying patients are lacking. OBJECTIVES: To describe the frequency, indication, and modality of palliative sedation (PS) in patients followed at home. METHODS: A retrospective analysis of home care cancer patients was performed. Patients who received PS before dying were selected and information about epidemiologic characteristics, indications, duration, drugs, and outcomes was collected. RESULTS: Of 370 medical charts of patients who died at home, 49 patients received PS before dying. PS was proposed by the team, relatives, or both in 63.3%, 4.1%, and 32.6% of cases, respectively. Delirium alone or in combination with other symptoms was the most frequent indication to begin PS. Midazolam was the most frequently used drug to initiate PS (98%), at a mean dose of 28.1 mg/day, in combination with parenteral morphine (84.7%) at a mean dose of 25.4 mg/day. At the time of death, midazolam was administered in 98% of patients (mean dose 22.3 mg/day), combined with parenteral morphine in 87.8% of patients (mean dose 28.1 mg/day). Satisfaction for physicians and principal caregivers after PS was good in 46 and 48 cases, respectively. CONCLUSION: PS at home seems to be a feasible treatment option among selected patients and makes a potentially important contribution to improving care for those who choose to die at home

    Prognostic factors of survival in patients with advanced cancer admitted to home care

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    Abstract CONTEXT: Data regarding prognostication of life expectancy in patients with advanced cancer are of paramount importance to patients, families, and clinicians. However, data regarding patients followed at home are lacking. OBJECTIVES: The aim of this study was to evaluate the correlation between various factors recorded at the beginning of home care assistance and survival. METHODS: A sample of consecutive patients admitted to two home care programs was surveyed. A preliminary consensus was achieved as to the possible variables easy to be recorded at home. These included age at the time of home care admission, gender, residence, marital status, primary cancer diagnosis, Karnofsky Performance Status (KPS) score, measures of systolic blood pressure and heart rate, cyanosis, use of oxygen, and body temperature. The Edmonton Symptom Assessment System was used to record the intensity of each symptom. Patients were divided into two groups: patients with a survival of less than 10 days (short survival) and patients with a survival of 10 days or more (medium-long survival). RESULTS: Three hundred seventy-four consecutive patients admitted to home care programs were surveyed, of which 187 were male. The mean\ub1SD age was 72.1\ub112.7 years. The mean survival was 56.2\ub165 days. Mean survival was 71.5\ub167 days (287 patients) and 5.6\ub12.7 days (87 patients) in the short and medium-long survival groups, respectively. No association between type of tumor and survival was observed (P=0.162). Univariate logistic regression analysis revealed that male gender (P=0.020), older age (P=0.012), lower KPS scores (P<0.0005), systolic blood pressure less than 100 mmHg (P=0.003), heart rate greater than 100 beats per minute (P=0.0006), delirium (P=0.004), the use of oxygen (P=0.002), intensity of fatigue (P=0.006), drowsiness (P<0.0005), anorexia (P<0.0005), dyspnea (P<0.0005), poor sense of well-being (P<0.0005), and distress score (P<0.0005) were associated with a survival of less than 10 days. Marital status, residence, cognitive function, fever, pain, depression, and anxiety were not found to be significantly correlated with survival. In a multiple logistic regression model, low systolic blood pressure and high heart rate, gender, delirium, use of oxygen, KPS score, drowsiness, anorexia, and dyspnea were significantly correlated with a shorter survival. CONCLUSION: Low systolic blood pressure and high heart rate, male gender, poor KPS score, anorexia, and dyspnea were correlated with a shorter survival. Moreover, patients with low systolic blood pressure and high heart rate, male gender, poor KPS score, and greater intensity of anorexia and dyspnea are more likely to die within one week. The combination of physical symptoms from the Edmonton Symptom Assessment System and other parameters included in this study, which are simple to assess and are repeatable at home, should be further explored in future studies to provide a simple tool for use with patients with advanced cancer admitted to a home care program

    Tapentadol at medium to high doses in patients previously receiving strong opioids for the management of cancer pain.

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    Abstract Abstract Objective: The aim of this study was to assess the efficacy and tolerability of tapentadol (TP) for a period of 4 weeks in patients who were already treated by opioids. Methods: A convenience sample of 30 patients was selected for a prospective observational cohort study. Cancer patients who were receiving at least 60 mg of oral morphine equivalents were selected. Patients discontinued their previous opioid analgesics before starting TP, in doses calculated according the previous opioid consumption (1:3.3 ratio with oral morphine equivalents). The subsequent doses were changed according to the patients' needs for a period of 4 weeks. Oral morphine was offered as a breakthrough pain medication. Pain and symptom intensity were recorded at weekly intervals. Distress score (DS) was calculated from the sum of symptom intensities. TP opioid escalation indexes (TPEI) for the study period were calculated. Results: Nineteen patients were male, and the mean age was 63.5 years (±11.5). The mean Karnofsky status was 62.9 (±10). The mean dose of oral morphine equivalents before switching to TP was 112 mg (±57) and the initial mean dose of TP was 343 mg (±150). Pain intensity significantly decreased. Tapentadol escalation index in percentage was 1.26 (TPEI% ± 2.6) and Tapentadol escalation index in mg was 2.76 (TPEImg ± 4.96). No significant relationships were found with primary tumor (TPEI%, p = 0.204; TPEImg, p = 0.180), pain mechanism (TPEI%, p = 0.863; TPEImg, p = 0.846), age (TPEI%, p = 0.882; TPEImg, p = 0.884), or gender (TPEI%, p = 0.287; TPEImg, p = 0.325). DS decreased, but non-significantly (p = 0.1). Ten patients did not complete the study period: five patients discontinued TP for uncontrolled pain, despite increasing doses of TP over 600 mg/day. Two patients discontinued TP for adverse effects and three patients dropped out, one patient for poor compliance and two patients for unrecorded reasons. Conclusion: In our sample, TP used in doses of 350-450 mg/day was well tolerated and effective in opioid tolerant patients with cancer pain and could be considered as a flexible drug to be used for the management of moderate to severe cancer pain. Like most studies in patients with cancer pain, it was limited by its open-label, uncontrolled design, the number of patients lost in follow-up, and discontinuation of the treatment for several reasons. Further studies in a large number of patients should confirm these preliminary results

    Pain intensity as prognostic factor in cancer pain management

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    Aim: The aim of this study was to prospectively assess the prognostic value of initial pain intensity and its duration in advanced cancer patients. Methods: A prospective study was conducted in a sample of patients with cancer requiring pain control. Patients underwent standard analgesic strategies used in our palliative care units. Pain intensity was measured at admission (T0) and after successful dose titration or opioid/route switching within a week (Ts). Patients were also asked about their pain intensity reported 15 days before admission (T-15). Doses of opioids and duration of opioid use were recorded. Patients were also assessed for the presence of incident pain, neuropathic pain, alcoholism, delirium, and symptom intensity, including items representing psychological distress. One week after or at time of stabilization (Ts), the opioid response was clinically graded as follows: (1) good pain control; (2) adequate pain control requiring more aggressive opioid escalation; (3) adequate pain control associated with the occurrence of adverse effects; (4) incapacity to achieve pain control within a week. Opioid escalation indexes and days for dose finding were also recorded. Results: Pain intensity at T0 and at T-15, opioid doses, duration of opioid therapy, and age were associated with more complex analgesic therapies, which were effective in almost all patients within a week. Conclusion: High levels of pain intensity, often due to previous undertreatment, are predictive of more complex analgesic treatment. Opioid tolerance, as well as younger age, may also play a role
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