Breakthrough pain in patients with abdominal cancer pain.

Abstract OBJECTIVE: Characterization of breakthrough cancer pain (BTcP) in patients with abdominal cancer is lacking. The aim of this study was to assess the characteristics of BTcP in patients with abdominal cancer pain. PATIENTS AND METHODS: In an observational cohort study, from a consecutive sample of patients admitted to a pain relief and supportive care unit for a period of 13 months, patients with abdominal disease due to cancer, including primary cancer or metastases, were assessed for the presence of chronic abdominal pain; its mechanism, intensity of background pain, and pain flares, which were distinguishable from the baseline pain, were recorded. Patients presenting with pain flares were assessed regarding the causes and the possible factors associated with it. Patients were reassessed when background pain control was considered optimal. RESULTS: From a sample of 522 patients admitted to an acute pain relief and palliative care unit in a period of 13 months, 100 patients with abdominal disease were available. The mean age was 65.3 years (SD\ub111.4); of the 100 patients, 45 (45%) were males. The mean Karnofsky status was 47.7 (SD\ub111.1). At admission (T0), 67 patients (67%) had background pain with mean pain intensity of 4.9 (SD\ub11.6). Sixty-one patients of those with background pain (91%) had superimposed and well-distinguished pain flares. After analgesic optimization (T1), the mean background pain intensity was 1.7 (SD\ub11.2), and 55.2% of patients had BTcP episodes. The difference with T0 was significant (P<0.0005). CONCLUSIONS: This preliminary study provides new insights on the characteristics of BTcP in a subclass of patients with abdominal disease. It has been estimated that about 55% of patients with well-controlled background pain will develop BTcP episodes. This percentage was higher (about 90%) in patients who presented with uncontrolled background pain, underlying the need to better characterize patients with BTcP, only after a careful optimization of basal pain, as considered by the definition of BTcP

Changes of QTc interval after opioid switching to oral methadone.

Abstract A consecutive sample of patients who were switched from strong opioids to methadone in a period of 1 year was surveyed. QTc was assessed before switching (T0) and after achieving adequate analgesia and an acceptable level of adverse effects (Ts). Twenty-eight of 33 patients were switched to methadone successfully. The mean initial methadone doses at T0 were 67.1 mg/day (SD \ub180.2, range 12-390). The mean QTc interval at T0 was 400 ms (SD \ub130, range 330-450). The mean QTc interval at Ts (median 5 days) was 430 ms (SD \ub126, range 390-500). The difference (7.7 %) was significant (p\u2009<\u20090.0005). Only two patients had a QTc of 500 ms. No serious arrhythmia was observed. At the linear regression analysis, there was no significant association between mean opioid doses expressed as oral morphine equivalents and QTc at T0 (p\u2009=\u20090.428), nor between mean methadone doses and QTc at Ts (p\u2009=\u20090.315). No age differences were found with previous opioid doses (p\u2009=\u20090.917), methadone doses (p\u2009=\u20090.613), QTc at T0 (p\u2009=\u20090.173), QTc at Ts (p\u2009=\u20090.297), and final opioid-methadone conversion ratio (p\u2009=\u20090.064). While methadone used for opioids switching seems to be an optimal choice to improve the opioid response in patients poorly responsive to the previous opioid, the possible QTc prolongation should be of concern despite not producing clinical consequences in this group of patients. A larger number of patients should be assessed to quantify the risk of serious arrhythmia

Spontaneous bilateral tubal pregnancy in a nulliparous woman. Laparoscopic diagnosis and treatment

A 34 year-old nulliparous woman was referred to our Department, complaining of vaginal bleeding and intermittent lower abdominal cramping. serum level of β-hCG was 4954 IU/L. Transvaginal ultrasound examination revealed no gestational sac in the uterine cavity and a right adnexal mass, suggestive of ectopic pregnancy; left adnexal area appeared regular. At laparoscopy, the presence of an ectopic pregnancy was confirmed in the right tube; on the left side, surprisingly, there was an intact infundibular ectopic pregnancy. Right tuba was removed; considering the condition of nulliparous of the patient, we decided to perform a linear salpingostomy. Histologic exam confirmed the diagnosis of spontaneous bilateral tubal ectopic pregnancies

Episodic breathlessness with and without background dyspnea in advanced cancer patients admitted to an acute supportive care unit

Aim: To characterize episodic breathlessness (EB) in patients with advanced cancer, and to determine factors influencing its clinical appearance. Methods: A consecutive sample of advanced cancer patients admitted to an acute palliative care unit was surveyed. Continuous dyspnea and EB were measured by a numerical scale. The use of drugs used for continuous dyspnea and EB was recorded. Patients were asked about the characteristics of EB (frequency, intensity, duration and triggers). The Multidimensional dyspnea profile (MDP), the Brief dyspnea inventory (BDI), the Athens sleep scale (AIS) and the Hospital Anxiety and Depression Scale (HADS) were also administered. Results: From 439 advanced cancer patients surveyed, 34 and 27 patients had EB, without and with background dyspnea, respectively. The mean intensity and the number of episodes were higher in patients with background dyspnea (p &lt; 0.0005 and p = 0.05, respectively). No differences in duration were observed. Most episodes lasted &lt;10 min. A recognizable cause triggering EB was often found. The presence of both background dyspnea and EB was associated with higher values of MDP and BDI. EB was independently associated with frequency and intensity of background dyspnea (OR = 20.9, 95% CI (Confidence interval) 9.1–48.0; p &lt; 0.0005 and OR = 1.97, 95% CI 1.09–3.58; p = 0.025, respectively) and a lower Karnofsky level (OR = 0.96, 95%CI 0.92–0.98, p = 0.05). Discussion: EB may occur in patients with and without continuous dyspnea, and is often induced by physical and psychological factors. EB intensity is higher in patients with continuous dyspnea. The duration was often so short that the use of drugs, as needed, may be too late, unless administered pre-emptively when the trigger was predictable

Dosing fentanyl buccal tablet for breakthrough cancer pain: dose titration versus proportional doses

Abstract OBJECTIVES: The aim of this study was to compare the efficacy and safety of doses of fentanyl buccal tablet (FBT) proportional to doses of opioids used for background analgesia versus dose titration starting with the minimal dose for the management of breakthrough cancer pain (BTcP). METHODS: A total of 82 cancer patients with BTcP who were receiving strong opioids in doses of at least 60 mg of oral morphine equivalents and having acceptable background analgesia, were selected for a multicenter unblinded study. Forty-one patients were randomized to receive FBT in doses proportional to the daily opioid doses for four consecutive episodes of BTcP (group P). Forty-one patients underwent dose titration of FBT, with an initial dose of 100 µg, for four consecutive episodes (group T). Pain intensity and symptoms associated with opioid therapy were measured before administering any dose of FBT (T0) and 15 minutes after (T15). RESULTS: In all, 80 patients were considered for analysis (39 and 41 patients in group P and T, respectively). Patients were receiving a mean of 126 ± 100 mg of oral morphine equivalents (range 60-480 mg) for background analgesia. A total of 293 episodes of BTcP (144 and 149 in group P and T, respectively) were treated and considered for analysis. No differences were found in the decrease of pain intensity between the two groups. However, in patients receiving doses of oral morphine equivalents of >120 mg/day, a significant number of patients obtained a decrease in pain intensity >50% in group P in comparison with group T (p = 0.040). Also, the need for rescue medication was significantly more frequently reported in group T for the first episode of BTcP (p < 0.0005). No differences in the level of adverse effects were observed between the two groups. No differences in patients' satisfaction were reported. CONCLUSION: According to the data obtained in this study, there is no evidence for the use of dose titration in the management of BTcP in opioid-tolerant patients. Indeed, doses proportional to basal opioid regimen for background pain seem to be effective and safe in the majority of patients. Further studies should confirm this data in patients receiving higher doses of opioids, with other rapid-onset opioids, and in other settings

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

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

The frequency of alcoholism in patients with advanced cancer admitted to an acute palliative care unit and a home care program

Context Cancer patients with a history of alcoholism may be problematic. The frequency of alcoholism among patients with advanced cancer has never been reported in Italy or other European countries. Objectives The aim of this prospective study was to determine the frequency of alcoholism, assessed with a simple and validated instrument, among patients with advanced cancer who were referred to two different palliative care settings: an acute inpatient palliative care unit (PCU) of a comprehensive cancer center in a metropolitan area and a home care program (HCP) in a territorial district, localized in the mountains of Italy. Methods A consecutive sample of patients admitted to an inpatient PCU and to an HCP was assessed for a period of eight months. Each patient who agreed to be interviewed completed the Cut down, Annoyed, Guilty, Eye-opener (CAGE) questionnaire. Patients were then interviewed informally to gather information about their history with alcohol. Results In total, 443 consecutive patients were surveyed; data from 249 to 194 patients were collected in the PCU and HCP, respectively, in the eight-month period. The mean age was 66.4 (SD 12.7) years, and 207 were males. The mean Karnofsky level was 54.2 (SD 14.6). Eighteen patients were CAGE positive (4.06%). Males (Pearson Chi-squared, P = 0.027) and younger patients (analysis of variance test, P = 0.009) were more likely to be CAGE positive. Informal interviews revealed that 17 patients (3.83%) were alcoholics or had a history of alcoholism, and that alcoholism was strongly correlated with CAGE (Pearson Chi-squared, P < 0.0001). Conclusion Only a minority of patients were CAGE positive, with a similar frequency in the PCU and HCP settings. CAGE-positive patients were more likely to be male and younger, independent of diagnosis and performance status. CAGE was positively correlated with informal interviews for detecting alcoholism. As CAGE patients express more symptom distress, it is important to detect this problem with a simple tool that has a high sensitivity and specificity and is easy to use even in patients with advanced disease

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

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