Oxycodone for Cancer Pain in Adult Patients

Clinical Question: Is oxycodone associated with greater efficacy and fewer adverse events compared with alternative analgesics for cancer pain? Bottom Line: Oxycodone was not associated with superior cancer pain relief or fewer adverse effects compared with other strong opioids, such as morphine or oxymorphone. However, the quality of the evidence was low. Many patients with cancer experience moderate or severe pain requiring treatment with strong opioids. However, not all opioids are well tolerated by all patients. This JAMA Clinical Evidence Synopsis summarizes a published Cochrane review1 that examined the association of oxycodone (any formulation or route of administration) compared with placebo or an active drug (including alternative forms of oxycodone) for treating cancer pain in adults

Using qualitative research to overcome the shortcomings of systematic reviews when designing of a self-management intervention for advanced cancer pain

Objectives: To identify the key components for a self-management intervention for advanced cancer pain using evidence drawn from systematic reviews of complex interventions and syntheses of qualitative research. Methods: Evidence from up-to-date systematic reviews was prioritised. Searches were initially undertaken to identify systematic reviews of effectiveness in Cinahl, Medline, Embase, PsycInfo and the Cochrane Database of Systematic Reviews from 2009-June 2014, using validated search terms. Subsequent searches to identify qualitative systematic reviews were undertaken in Cinahl, Medline, Embase, and PsycInfo from 2009- January 2015. The results of the two sets of reviews were integrated using methods based on constant comparative techniques. Results: Four systematic reviews examining interventions for the self-management of advanced cancer pain were identified. Whilst each review recommended some attributes of a pain management intervention, it was not possible to determine essential key components. Subsequent searches for qualitative evidence syntheses identified three reviews. These were integrated with the effectiveness reviews. The integration identified key components for a self-management intervention including: individualised approaches to care; the importance of addressing patients’ knowledge, skills and attitudes towards pain management; and the significance of team approaches and inter-disciplinary working in the management of pain. Conclusion: Implementing the findings from systematic reviews of complex interventions is often hindered by a lack of understanding of important contextual components of care, often provided by qualitative research. Using both types of data to provide answers for practice demonstrates the benefits of incorporating qualitative research in reviews of complex interventions by ensuring the strengths of qualitative and quantitative research are combined and that their respective weaknesses are overcome

Supporting self-management of pain by patients with advanced cancer: views of palliative care professionals

Purpose: The aim of the study is to ascertain the views of specialist palliative care professionals on patient selfmanagement of cancer pain in order to inform the development of a new educational intervention to support selfmanagement. Methods: This is a qualitative research study using focus group interviews. Results: Participants viewed self-management of cancer pain as desirable and achievable but also as something that could be problematic. Challenges to self-management were perceived in patient attitudes and behaviours, professionals’ own beliefs and actions and the wider social system. Practitioners: showed awareness of potential tension between their espoused views (the desirability that patients manage pain autonomously) and their tacit views (the undesirability of patients managing pain in ways which conflict with professionals’ knowledge and identity). Conclusions: Practitioners espoused patient-centred professional practice which inclined them towards supporting self-management. They showed awareness of factors which might inhibit them from effectively incorporating education and support for self-management into routine practice

Identifying professionals' needs in integrating electronic pain monitoring in community palliative care services: an interview study

Background: Poor pain assessment is a barrier to effective pain control. There is growing interest internationally in the development and implementation of remote monitoring technologies to enhance assessment in cancer and chronic disease contexts. Findings describe the development and testing of pain monitoring systems but research identifying the needs of health professionals to implement routine monitoring systems within clinical practice is limited. Aim: To inform the development and implementation strategy of an electronic pain monitoring system, PainCheck, by understanding palliative care professionals’ needs when integrating PainCheck into routine clinical practice. Design: Qualitative study using face-to-face interviews. Data were analysed using framework analysis Setting/participants: Purposive sample of health professionals managing the palliative care of patients living in the community Results: Fifteen interviews with health professionals took place. Three meta-themes emerged from the data: 1) Uncertainties about integration of PainCheck and changes to current practice; 2) Appraisal of current practice; 3) Pain management is everybody’s responsibility Conclusions: Even the most sceptical of health professionals could see the potential benefits of implementing an electronic patient-reported pain monitoring system. Health professionals have reservations about how PainCheck would work in practice. For optimal use PainCheck needs embedding within existing electronic health records. Electronic pain monitoring systems have the potential to enable professionals to support patients’ pain management more effectively but only when barriers to implementation are appropriately identified and addressed

Spinal cord stimulation for cancer-related pain in adults

Background: This is an update of a review first published in The Cochrane Library in Issue 3, 2013. Cancer-related pain places a heavy burden on public health with related high expenditure. Severe pain is associated with a decreased quality of life in patients with cancer. A significant proportion of patients with cancer-related pain are under-treated. There is a need for more effective control of cancer-related pain. Spinal cord stimulation (SCS)may have a role in pain management. The effectiveness and safety of SCS for patients with cancer-related pain is currently unknown. Objectives: This systematic review evaluated the effectiveness of SCS for cancer-related pain compared with standard care using conventional analgesic medication. We also appraised risk and potential adverse events associated with the use of SCS. Search methods: This is an update of a review first published in The Cochrane Library in Issue 3, 2013. The search strategy for the update was the same as in the original review. We searched the following bibliographic databases in order to identify relevant studies: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library;MEDLINE; EMBASE; and CBM(Chinese Biomedical Database) in October 2014. We also handsearched relevant journals. There were no language restrictions. Selection criteria: We planned to include randomised controlled trials (RCTs) that directly compared SCS with other interventions with regards to the effectiveness of pain management.We also planned to include cross-over trials that compared SCS with another treatment.We planned to identify non-randomised controlled trials but these would only be included if no RCTs could be found. Data collection and analysis: The literature search for the update of this review found 121 potentially eligible articles. The initial search strategy yielded 430 articles. By scrutinising titles and abstracts, we found 412 articles irrelevant to the analytical purpose of this systematic review due to different scopes of diseases or different methods of intervention (intrathecal infusion system; oral medication) or aims other than pain control (spinal cord function monitoring, bladder function restoration or amelioration of organ metabolism). The remaining 18 trials were reviewed as fullmanuscripts. No RCTs were identified. Fourteen sporadic case reports and review articles were excluded and four beforeand- after case series studies (92 participants) were included. Two review authors independently selected the studies to be included in the review according to the prespecified eligibility criteria. A checklist for methodological quality of non-randomised controlled trials was used (STROBE checklist) and all review authors discussed and agreed on the inclusion of trials and the results of the quality assessment. Main results: No new studies were identified for inclusion in this update of the review. Four before-and-after case series studies (a total of 92 participants) met our criteria for inclusion in the previous version of the review. All included trials adopted a visual analogue scale (VAS) to evaluate pain relief. Heterogeneity existed in terms of baseline characteristics, electrode and stimulator parameters, level of implantation and route of implantation; each trial reported data differently. In two trials, pain relief was achieved in 76% (48/63) of participants at the end of the follow-up period. In the third trial, pre-procedure VAS was 6 to 9 (mean 7.43 ); the one-month postimplant VAS was 2 to 4 (mean 3.07); the 12-month post-implant VAS was 1 to 3 (mean 2.67). In the fourth trial, the pre-procedure VAS was 6 to 9 (mean 7.07); 1 to 4 (mean 2.67) at one-month; 1 to 4 (mean 1.87) at 12 months. Analgesic use was largely reduced. The main adverse events were infection of sites of implantation, cerebrospinal fluid (CSF) leakage, pain at the sites of electrodes, dislodgement of the electrodes, and system failure; however, the incidence in participants with cancer could not be calculated. Since all trials were small, non-randomised controlled trials, they carried high or unclear risk of all types of bias. Authors’ conclusions: Since the first publication of this review, no new studies were identified. Current evidence is insufficient to establish the role of SCS in treating refractory cancer-related pain. Future randomised studies should focus on the implantation of SCS in participants with cancer related pain

What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city

Objective For patients with advanced cancer, several randomised controlled trials have shown that access to palliative care at least 6 months before death can improve symptoms, reduce unplanned hospital admissions, minimize aggressive cancer treatments and enable patients to make choices about their end of life care, including exercising the choice to die at home. This study determines in a UK population the duration of palliative care before death and explores influencing factors. Design This retrospective cohort study analysed referrals to three specialist palliative care services; a hospital based inpatient palliative care team, and two community based services (hospices). For each patient referred to any of the above services we identified the date of first referral to that team and calculated the median interval between first referral and death. We also calculated how referral time varied by age, sex, diagnosis and type of palliative care service. Participants 4,650 patients referred to specialist palliative care services in Leeds UK between April 2012 and March 2014. Results Median age of the sample was 75 years. 3,903 (84.0%) patients had a diagnosis of cancer. Age, diagnosis and place of referral were significant predictors of duration of palliative care before death. Age was independently associated (J = 2672078, z = -392046.14, r = .01) with duration of palliative care regardless of diagnosis. Patients over 75 years have 29 fewer days of palliative care than patients under 50. Patients with non-cancer diagnoses have 13 fewer days of palliative care than patients with cancer. Additionally, patients referred to hospital palliative care receive 24.5 fewer days palliative care than those referred to community palliative care services. Conclusions The current timing of referral to palliative care may limit the benefits to patient in terms of improvements in end of life care, particularly for older patients and patients with conditions other than cancer

Associated Factors with Colorectal Cancer (CRC) Screening Awareness in the Black Belt Region of Alabama: a Comparison among Three Types of CRC Screening

Objective: The present study aims to assess the levels of awareness of three types of CRC screening tests (FIT or FBOT, sigmoidoscopy, and colonoscopy) among African Americans living in the Black Belt area, and examine the factors associated with awareness of CRC screening tests among this population. Methods: The current study utilized a survey research design. Univariate analysis was used to assess the awareness of three types of colorectal cancer screening: FIT or FOBT, sigmoidoscopy, and colonoscopy. Three sets of logistic regression analyses were conducted to examine the factors associated with the awareness level of each of the three colorectal cancer screening types among study participants. Results: More than half of study participants heard of FOBT/FIT. Only one third of participants heard of sigmoidoscopy. The majority of study participants heard of colonoscopy. Participation in socializing groups was found to be positively associated with awareness of all three types of CRC screening. Employment and having a primary care physician were positively associated with FOBT/FIT and colonoscopy. Study participants with a primary care physician demonstrated awareness of FOBT/FIT and colonoscopy Conclusion: Health education on different types of CRC screening especially FOBT/FIT and sigmoidoscopy is needed for the study population. CRC screening awareness among rural African Americans is likely to be improved by removing barriers of accessing primary physicians or other healthcare resources. Health education intervention in community setting or socializing groups such as clubs or religious group can potentially improve awareness of CRC screening

Tripartite Entanglement in Noninertial Frame

The tripartite entanglement is examined when one of the three parties moves with a uniform acceleration with respect to other parties. As Unruh effect indicates, the tripartite entanglement exhibits a decreasing behavior with increasing the acceleration. Unlike the bipartite entanglement, however, the tripartite entanglement does not completely vanish in the infinite acceleration limit. If the three parties, for example, share the Greenberger-Horne-Zeilinger or W-state initially, the corresponding $\pi$-tangle, one of the measures for tripartite entanglement, is shown to be $\pi/6 \sim 0.524$ or 0.176 in this limit, respectively. This fact indicates that the tripartite quantum information processing may be possible even if one of the parties approaches to the Rindler horizon. The physical implications of this striking result are discussed in the context of black hole physics.Comment: 19 pages, 5 figure

A critical appraisal of gabapentinoids for pain in cancer patients.

Gabapentinoids are frequently used in the management of cancer pain. In recent Cochrane systematic reviews, although there was an abundance of evidence relating to non-cancer pain, only a few studies related to cancer pain. This review summarizes recent randomised controlled trials (RCTs) evaluating the use of gabapentinoids for tumour-related (as monotherapy or part of combination therapy) and treatment-related pain. Recent findings: for tumour-related pain, ten out of thirteen studies showed statistically significant benefits in favour of gabapentinoids. When used, as part of monotherapy or combination therapy, benefits were observed in five out of six studies evaluating gabapentin, and in six out of eight studies evaluating pregabalin. For treatment-related pain, none of the four studies (two gabapentin, two pregabalin) showed statistically significant benefits in favour of gabapentinoids. Unfortunately, many of the studies included were limited by small sample size, lack of blinding, and inadequate follow-up. Summary: more and better quality studies are required, although it may be challenging to accomplish in this patient population. Gabapentinoids may offer benefits to cancer patients with pain, but careful titration and monitoring of adverse effects is necessary