Quality use of medicines for palliative care

Many of the drugs commonly used in palliative care are not listed on the Pharmaceutical Benefits Scheme in Australia and are therefore not freely available to patients outside the acute hospital system. In an attempt to address the inequity faced by patients being cared for in the community or hospices, the Palliative Care Medicines Working Group was established by the Australian Government. This has resulted in a separate palliative section within the Schedule of Pharmaceutical Benefits Scheme which allows for authority prescribing of a number of medications that may be required by a palliative care patient. This paper discusses the medications currently on this listing, the processes by which they were selected and the ongoing efforts to broaden access to required medications

Defining refractory pain in cancer for clinicians and researchers

Managing pain in people with cancer remains a challenge, especially in those referred to as having refractory pain. But what is refractory or intractable pain? Until there is a standard definition there is the risk that: a) clinically, new medications are continuously added, each with diminishing returns in reducing pain, and each with an increasing likelihood of toxicity as the only noticeable change; and b) in research, there will be differing baselines for the operational definition of refractory, making it difficult to adopt the findings into practice, or to compare clinical trials in any systematic way

Progressing an evidence-base beyond case series

High-quality randomized trials in hospice and palliative care are achievable to provide quality evidence to guide our practice especially if several sites work together to conduct the trial. Palliative medicine is a specialty that is contributing more and more to the care of patients with life limiting disease. It is time we based this practice on highquality evidence and that can only come with high-quality research

Microwave Signatures of Melting/Refreezing Snow: Observations and Modeling Using Dense Medium Radiative Transfer Theory

Microwave brightness temperatures of snow covered terrains can be modeled by means of the Dense Radiative Transfer Medium Theory (DMRT). In a dense medium, such as snow, the assumption of independent scattering is no longer valid and the scattering of correlated scatterers must be considered. In the DMRT, this is done considering a pair distribution function of the particles position. In the electromagnetic model, the snowpack is simulated as a homogeneous layer having effective permittivity and albedo calculated through the DMRT. In order to account for clustering of snow crystals, a model of cohesive particles can be applied, where the cohesion between the particles is described by means of a dimensionless parameters called stickiness (z), representing a measure of the inversion of the attraction of the particles. The lower the z the higher the stickiness. In this study, microwave signatures of melting and refreezing cycles of seasonal snowpacks at high altitudes are studied by means of both experimental and modeling tools. Radiometric data were collected 24 hours per day by the University of Michigan Tower Mounted Radiometer System (TMRS). The brightness temperatures collected by means of the TMRS are simulated by means of a multi-layer electromagnetic model based on the dense medium theory with the inputs to the model derived from the data collected at the snow pits and from the meteorological station. The paper is structured as follows: in the first Section the temperature profiles recorded by the meteorological station and the snow pit data are presented and analyzed; in the second Section, the characteristics of the radiometric system used to collect the brightness temperatures are reported together with the temporal behavior of the recorded brightness temperatures; in the successive Section the multi-layer DMRT-based electromagnetic model is described; in the fourth Section the comparison between modeled and measured brightness temperatures is discussed. We dedicate the last Section to the conclusions and future works

Corticosteroids for the management of cancer-related pain in adults (Review)

Background: One of the most feared symptoms associated with cancer is pain. Opioids remain the mainstay of pain treatment but corticosteroids are often used concurrently as co- or adjuvant analgesics. Due to their anti-inflammatory mechanism of action, corticosteroids are said to provide effective analgesia for pain associated with inflammation and in the management of cancer-related complications such as brain metastasis and spinal cord compression. However, corticosteroids have a wide range of adverse effects that are dose and time dependent. Objectives: To evaluate the efficacy of corticosteroids in treating cancer-related pain in adults. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 4), MEDLINE (OVID) (1966 to 29 September 2014), EMBASE (OVID) (1970 to 29 September 2014), CINAHL (1982 to 29 September 2014), Science Citation Index (Web of Science) (1899 to 29 September 2014) and Conference Proceedings Citation Index - Science (Web of Science) (1990 to 29 September 2014). Selection criteria: Any randomised or prospective controlled trial that included patients over 18 years with cancer-related pain were eligible for the review. Corticosteroids were compared to placebo or usual treatment and/or supportive care. Data collection and analysis: All review authors independently assessed trial quality and extracted data. We used arithmetic means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). Main results: Fifteen studies met the inclusion criteria, enrolling 1926 participants. The trial size varied from 20 to 598 patients. Most studies compared corticosteroids, particularly dexamethasone, to standard therapy. We included six studies with data at one week in the meta-analysis for pain intensity; no data were available at that time point for the remaining studies. Corticosteroid therapy resulted in less pain (measured on a scale of 0 to 10 with a lower score indicating less pain) compared to control at one week (MD 0.84 lower pain, 95% CI 1.38 to 0.30 lower; low quality evidence). Adverse events were poorly documented. Factors limiting statistical analysis included the lack of standardised measurements of pain and the use of different agents, dosages, comparisons and routes of drug delivery. Subgroup analysis according to type of cancer was not possible. The quality of this evidence was limited by the risk of bias of the studies and small sample size. The results were also compromised by attrition, with data missing for the enrolled patients. Authors' conclusions: The evidence for the efficacy of corticosteroids for pain control in cancer patients is weak. Significant pain relief was noted in some studies, albeit only for a short period of time. This could be important for patients with poor clinical status. Further trials, with increased numbers of participants, are needed to evaluate the safety and effectiveness of corticosteroids for the management cancer pain in adults, and to establish an ideal dose, duration of therapy and route of administration

Double-blind, placebo-controlled, randomized trial of octreotide in malignant bowel obstruction

Context Does octreotide reduce vomiting in cancer-associated bowel obstruction? Objectives To evaluate the net effect of adding octreotide or placebo to standardized therapies on the number of days free of vomiting for populations presenting with vomiting and inoperable bowel obstruction secondary to cancer or its treatment. Methods Twelve services enrolled people with advanced cancer presenting with vomiting secondary to bowel obstruction where surgery or anti-cancer therapies were not indicated immediately. In a double-blind study, participants were randomized to placebo or octreotide (600 μg/24 hours by infusion). Both arms received standardized supportive therapy (infusion of ranitidine [200 mg/24 hours], dexamethasone [8 mg/24 hours], and parenteral hydration [10-20 mL/kg/24 hours]). The primary outcome was patient-reported days free of vomiting at 72 hours. Results In a study that recruited to the numbers identified in its power calculation, 87 participants provided data at 72 hours (45, octreotide arm). Seventeen people (octreotide) and 14 (placebo) were free of vomiting for 72 hours (P = 0.67). Mean days free of vomiting were 1.87 (SD 1.10; octreotide) and 1.69 (SD 1.15; placebo; P = 0.47). An adjusted multivariate regression of the incidence of vomiting over the study showed a reduced number of episodes of vomiting in the octreotide group (incidence rate ratio = 0.40; 95% CI: 0.19-0.86; P = 0.019); however, people in the octreotide arm were 2.02 times more likely to be administered hyoscine butylbromide (P = 0.004), potentially reflecting increased colicky pain. Conclusion Although there was no reduction in the number of days free of vomiting, the multivariate analysis suggests that further study of somatostatin analogues in this setting is warranted

Impact of opioid therapy on sleep and respiratory patterns in adults with advanced cancer receiving palliative care

Context. In advanced cancer, abnormal sleep patterns may contribute to poor quality of life, but the impact of opioidrelated sleep disorders has not been explored in detail in these patients

Spatial Variability of Shortwave Irradiance for Snowmelt in Forests

The spatial variation of melt energy can influence snow cover depletion rates and in turn be influenced by the spatial variability of shortwave irradiance to snow. The spatial variability of shortwave irradiance during melt under uniform and discontinuous evergreen canopies at a U. S. Rocky Mountains site was measured, analyzed, and then compared to observations from mountain and boreal forests in Canada. All observations used arrays of pyranometers randomly spaced under evergreen canopies of varying structure and latitude. The spatial variability of irradiance for both overcast and clear conditions declined dramatically, as the sample averaging interval increased from minutes to 1 day. At daily averaging intervals, there was little influence of cloudiness on the variability of subcanopy irradiance; instead, it was dominated by stand structure. The spatial variability of irradiance on daily intervals was higher for the discontinuous canopies, but it did not scale reliably with canopy sky view. The spatial variation in irradiance resulted in a coefficient of variation of melt energy of 0.23 for the set of U. S. and Canadian stands. This variability in melt energy smoothed the snow-covered area depletion curve in a distributed melt simulation, thereby lengthening the duration of melt by 20%. This is consistent with observed natural snow cover depletion curves and shows that variations in melt energy and snow accumulation can influence snow-covered area depletion under forest canopies

Prepregnancy weight, gestational weight gain, and risk of growth affected neonates

BACKGROUND: In 2009, the Institute of Medicine published revised gestational weight gain (GWG) guidelines with changes notable for altered body mass index (BMI) categorization as per World Health Organization criteria and a stated range of recommended gain (11-20 pounds) for obese women. The goal of this study was to evaluate associations between maternal BMI-specific GWG adherence in the context of these new guidelines and risk of small for gestational age (SGA) and large for gestational age (LGA) neonates. METHODS: Subjects were a retrospective cohort of 11,203 live birth singletons delivered at 22-44 weeks at a Massachusetts tertiary care center between April 2006 and March 2010. Primary exposure was GWG adherence (inadequate, appropriate, or excessive) based on BMI-specific recommendations. SGA and LGA were defined as /=90th percentiles of U.S. population growth curves, respectively. The association between GWG adherence and SGA and LGA was examined in polytomous logistic regression models that estimated adjusted odds ratios (AOR) stratified by prepregnancy weight status, controlling for potential confounders. RESULTS: Before pregnancy, 3.8% of women were underweight, 50.9% were normal weight, 24.6% were overweight, and 20.6% were obese. Seventeen percent had inadequate GWG, and 57.2% had excessive GWG. Neonates were 9.6% SGA and 8.7% LGA. Inadequate GWG was associated with increased odds of SGA (AOR 2.51, 95% confidence interval [CI] 1.31-4.78 for underweight and AOR 1.78, 95% CI 1.42-2.24 for normal weight women) and decreased odds of LGA (AOR 0.5, 95% CI 0.47-0.73 for normal weight and AOR 0.56, 95% CI 0.34-0.90 for obese women). Excessive GWG was associated with decreased odds of SGA (AOR 0.59, 95% CI 0.47-0.73 for normal weight and AOR 0.64, 95% CI 0.47-0.89 for overweight women) and increased odds of LGA (AOR 1.76, 95% CI 1.38-2.24 for normal weight, AOR 2.99, 95% CI 1.92-4.65 for overweight, and AOR 1.55, 95% CI 1.10-2.19 for obese women). CONCLUSIONS: Efforts to optimize GWG are essential to reducing the proportion of SGA and LGA neonates, regardless of prepregnancy BMI

Radiative Transfer Modeling of a Coniferous Canopy Characterized by Airborne Remote Sensing

Solar radiation beneath a forest canopy can have large spatial variations, but this is frequently neglected in radiative transfer models for large-scale applications. To explicitly model spatial variations in subcanopy radiation, maps of canopy structure are required. Aerial photography and airborne laser scanning are used to map tree locations, heights, and crown diameters for a lodgepole pine forest in Colorado as inputs to a spatially explicit radiative transfer model. Statistics of subcanopy radiation simulated by the model are compared with measurements from radiometer arrays, and scaling of spatial statistics with temporal averaging and array size is discussed. Efficient parameterizations for spatial averages and standard deviations of subcanopy radiation are developed using parameters that can be obtained from the model or hemispherical photography