Pain control in palliative care settings

Background and Purpose: The goal of palliative care is symptom control in patients with advanced disease and improvement of their quality of life. Materials and Methods: Pain assessment can be done through numerous rating scales. It is important to quantify pain so that health care providers can provide the most sufficient pain therapy and determine the effectiveness of it. Results: Morphine is the »gold standard« as pain medication in palliative care. Patients receiving palliative care often require frequent escalations in opioid dosage to attain good pain control. If the patient’s pain cannot be controlled by using opioids co-adjuvant analgesics should be added. Conclusions: In pain control therapy we should apply the cancer pain algorithm named »analgesic elevator« which is suggested by IASP

Umirući bolesnik – koliko analgezije?

As human life is invaluable, each person has the right to humane and dignified care at the end of life. The aim of treatment is to achieve the best possible quality of life for the terminally ill. The emphasis should be placed upon quality rather than length of life. The care for dying patients with incurable diseases is provided through palliative care. Particular attention during treatment in this last part of life is paid to the control of pain. Malignant pain is most commonly therapy- and procedure-related pain, generally caused by somatic, visceral, and neuropathic mechanisms. Management of malignant pain involves the application of pharmacotherapy combined with cognitive-behavioral techniques. Opioids are the most efficient pharmacotherapeutic agents. However, their use is associated with a number of serious side effects, the most significant being respiratory depression. Numerous studies have proved that despite such an effect, there is no reason for their avoidance or any obstacle for their administration for pain management. Another, quite common reason for avoiding the use of opoids is the fear of addiction, which is an extremely rare occurrence in dying patients, according to scientific research results. Death is an integral part of life and the quality of life must be optimal to its very end, especially in terms of pain curing.Ljudski život ima neprocjenjivu vrijednost te svaki čovjek ima pravo da ga u dostojanstvu završi. Svakom bi bolesniku trebalo omogućiti da umiranje; kao završni dio života proživi što je moguće kvalitetnije. Naglasak bi trebao biti na kvaliteti; a ne na duljini života. Briga za umiruće bolesnike čija je bolest neizlječiva provodi se putem palijativne skrbi. Najvažniju komponentu takvog liječenja čini adekvatna kontrola boli. Najčešći izvor boli u malignih bolesnika su terapijska i proceduralna bol. Malignu bol najčešće čini kombinacija somatske; visceralne i neuropatske boli. U liječenju boli nužno je uz farmakoterapijske pripravke primijeniti i kognitivno-biheviorističke metode. Od farmakoterapijskih pripravaka treba izdvojiti opioide. Smatraju se učinkovitim lijekom; ali njihova primjena se povezuje sa većim brojem ozbiljnih nuspojava od koji treba izdvojiti depresiju disanja. Mnogobrojne su studije dokazale da navedeno nije razlog za njihovo izbjegavanje u liječenju boli. Čest razlog nekorištenja opioida jest također i strah od pojave ovisnosti koja se prema znanstvenim podacima u umirućih bolesnika javlja izrazito rijetko. Smrt je sastavni dio života te cilj liječenja svakog umirućeg bolesnika mora biti postizanje optimalne kvalitete života bolesnika prilikom čega najveću pažnju treba posvetiti liječenju boli

Umirući bolesnik – koliko analgezije?

As human life is invaluable, each person has the right to humane and dignified care at the end of life. The aim of treatment is to achieve the best possible quality of life for the terminally ill. The emphasis should be placed upon quality rather than length of life. The care for dying patients with incurable diseases is provided through palliative care. Particular attention during treatment in this last part of life is paid to the control of pain. Malignant pain is most commonly therapy- and procedure-related pain, generally caused by somatic, visceral, and neuropathic mechanisms. Management of malignant pain involves the application of pharmacotherapy combined with cognitive-behavioral techniques. Opioids are the most efficient pharmacotherapeutic agents. However, their use is associated with a number of serious side effects, the most significant being respiratory depression. Numerous studies have proved that despite such an effect, there is no reason for their avoidance or any obstacle for their administration for pain management. Another, quite common reason for avoiding the use of opoids is the fear of addiction, which is an extremely rare occurrence in dying patients, according to scientific research results. Death is an integral part of life and the quality of life must be optimal to its very end, especially in terms of pain curing.Ljudski život ima neprocjenjivu vrijednost te svaki čovjek ima pravo da ga u dostojanstvu završi. Svakom bi bolesniku trebalo omogućiti da umiranje; kao završni dio života proživi što je moguće kvalitetnije. Naglasak bi trebao biti na kvaliteti; a ne na duljini života. Briga za umiruće bolesnike čija je bolest neizlječiva provodi se putem palijativne skrbi. Najvažniju komponentu takvog liječenja čini adekvatna kontrola boli. Najčešći izvor boli u malignih bolesnika su terapijska i proceduralna bol. Malignu bol najčešće čini kombinacija somatske; visceralne i neuropatske boli. U liječenju boli nužno je uz farmakoterapijske pripravke primijeniti i kognitivno-biheviorističke metode. Od farmakoterapijskih pripravaka treba izdvojiti opioide. Smatraju se učinkovitim lijekom; ali njihova primjena se povezuje sa većim brojem ozbiljnih nuspojava od koji treba izdvojiti depresiju disanja. Mnogobrojne su studije dokazale da navedeno nije razlog za njihovo izbjegavanje u liječenju boli. Čest razlog nekorištenja opioida jest također i strah od pojave ovisnosti koja se prema znanstvenim podacima u umirućih bolesnika javlja izrazito rijetko. Smrt je sastavni dio života te cilj liječenja svakog umirućeg bolesnika mora biti postizanje optimalne kvalitete života bolesnika prilikom čega najveću pažnju treba posvetiti liječenju boli

Placebo in the Treatment of Pain

Placebo is the use of the substance or procedure without specific activity for the condition that is trying to be healed. In medicine, benefits of placebo effect are used since 1985 and 1978 placebo effect was first scientifically confirmed. It was found that placebo induced analgesia depends on the release of endogenous opiates in the brain and that the placebo effect can be undone using the opiates antagonist naloxone. Functional magnetic resonance imaging of the brain showed that placebo analgesia was obtained regarding the activation and increased functional relationship between ant. cingulate, prefrontal, orbitofrontal, and insular cortex, nucleus accumlens, amygdala, periaqueduktalne gray matter and spinal cord. Placebo also facilitates descending inhibition of nociceptive reflexes through periacvaeductal gray substance. Placebo effect can be achieved in several ways: by using pharmacological preparations or simulation of operating or other procedures. This phenomenon is associated with perception and expectation of the patient. To achieve the effect of placebo it is essential degree of the suggestions of the person who prescribe a placebo, and the degree of belief of the person receiving the placebo. Expected effect of placebo is to achieve the same effect as the right remedy. Achieved placebo effect depends on the way of presentation. If a substance is presented as harmful, it may cause harmful effects, called »nocebo« effect. Placebo effect is not equal in all patients, same as the real effect of the drug is not always equal in all patients. Application of placebo in terms of analgesia will cause a positive response in 35% of patients. Almost the same percentage (36%) of patients will respond to treatment with morphine in medium doses (6–8 mg). Therefore, one should remember that response to placebo does not mean that a person simulates the pain and then it is unethical to withhold the correct treatment especially in light of findings that the prefrontal cortex is activated expecting liberation of pain and how this action reduce activities in brain regions responsible for sensation of pain (thalamus, somatosensory cortex and other parts of the cortex). However, the use of placebos is ethically, legally and morally very dubious. The basis for the placebo effect is deception. It undermines honest relationship and trust between doctor and patient which is extremely important for successful treatment. Consciously giving placebos to patients for a condition that can be adequately treated, with prejudice the right of patients to the best care possible, opens up many bioethical issues. Despite all the current knowledge level, placebo effect remains still a scientific mystery

Placebo in the Treatment of Pain

Placebo is the use of the substance or procedure without specific activity for the condition that is trying to be healed. In medicine, benefits of placebo effect are used since 1985 and 1978 placebo effect was first scientifically confirmed. It was found that placebo induced analgesia depends on the release of endogenous opiates in the brain and that the placebo effect can be undone using the opiates antagonist naloxone. Functional magnetic resonance imaging of the brain showed that placebo analgesia was obtained regarding the activation and increased functional relationship between ant. cingulate, prefrontal, orbitofrontal, and insular cortex, nucleus accumlens, amygdala, periaqueduktalne gray matter and spinal cord. Placebo also facilitates descending inhibition of nociceptive reflexes through periacvaeductal gray substance. Placebo effect can be achieved in several ways: by using pharmacological preparations or simulation of operating or other procedures. This phenomenon is associated with perception and expectation of the patient. To achieve the effect of placebo it is essential degree of the suggestions of the person who prescribe a placebo, and the degree of belief of the person receiving the placebo. Expected effect of placebo is to achieve the same effect as the right remedy. Achieved placebo effect depends on the way of presentation. If a substance is presented as harmful, it may cause harmful effects, called »nocebo« effect. Placebo effect is not equal in all patients, same as the real effect of the drug is not always equal in all patients. Application of placebo in terms of analgesia will cause a positive response in 35% of patients. Almost the same percentage (36%) of patients will respond to treatment with morphine in medium doses (6–8 mg). Therefore, one should remember that response to placebo does not mean that a person simulates the pain and then it is unethical to withhold the correct treatment especially in light of findings that the prefrontal cortex is activated expecting liberation of pain and how this action reduce activities in brain regions responsible for sensation of pain (thalamus, somatosensory cortex and other parts of the cortex). However, the use of placebos is ethically, legally and morally very dubious. The basis for the placebo effect is deception. It undermines honest relationship and trust between doctor and patient which is extremely important for successful treatment. Consciously giving placebos to patients for a condition that can be adequately treated, with prejudice the right of patients to the best care possible, opens up many bioethical issues. Despite all the current knowledge level, placebo effect remains still a scientific mystery

Effects of Dietary Counseling on Patients with Colorectal Cancer

Cancers of the colon and rectum together are second most common tumor type worldwide. The prognosis for the survival after disease progression is usually poor (1). Cancer anorexiacachexia syndrome is highly prevalent among patients with colorectal cancer, and has a large impact on morbidity and mortality, and on patient quality of life. Early intervention with nutritional supplementation has been shown to halt malnutrition, and may improve outcome in some patients (2). The etiology of cancer-associated malnutrition appears to be related to the pathological loss of inhibitory control of catabolic pathways, whose increased activities are not counterbalanced by the increased central and peripheral anabolic drive (3). The goals of nutritional support in patients with colorectal cancer are to improve nutritional status to allow initiation and completion of active anticancer therapies (chemotherapy and or radiotherapy) and improve quality of life (3, 4). Cancer growth and dissemination but also cancer treatments, including surgery, chemotherapy, and radiation therapy, interfere with taste, ingestion, swallowing, and digest food which leads to hypophagia. Also, chemotherapy agents may cause nausea and diarrhea (3, 4). Although many new agents are on the market to combat these symptoms, prevalence of colorectal cancer is still high (1). We studied the influence of nutritional support (counseling, nutritional supplements, megestrol acetate) on physical status and symptoms in patients with colorectal cancer during chemotherapy. The study was designed to investigate whether dietary counseling or oral nutrition commercial supplements during chemotherapy and/or BSC affected nutritional status and influence survival status prevalence in patients with colorectal cancer. Results: Three hundred and eighty-eight colorectal cancer patients were included in the study. Nottingham Screening Tool Questionnaire, Appetite Loss Scale and Karnofsky Performance Status were taken to evaluate the nutritive status of patients. Group I consisted of 215 patients who were monitored prospectively and were given nutritional support and in this group weight gain of 1,5 kg (0,6-2,8 kg) and appetite improvement was observed in patients with colorectal cancer. In both groups Karnofsky Performance Status didn’t change significantly reflecting the impact of the disease itself. Nutritional counseling, supplemental feeding and pharmacological support do temporarily stop weight loss and improve appetite, QoL and social life, but this improvement has no implications on patients KPS and course of their disease. Conclusion: These results encourage further studies with more specific nutritional supplementation in patients with colorectal cancer and probably in gastrointestinal oncology

ENTERAL NUTRITION OF THE PATIENT WITH MALIGNANCY

Malnutricija je česta u bolesnika s karcinomom, a enteralna prehrana metoda izbora za unos kalorijskih potreba u takvih bolesnika ako im je očuvana funkcija probavnog sustava. Uz enteralnu prehranu, očuvan je integritet i funkcija sluznice u probavnom sustavu, povećan nutricijski unos i smanjen gubitak tjelesne težine. Statistički su dokazane prednosti enteralne prehrane u odnosu na parenteralnu prehranu nakon kirurških zahvata kod onkoloških bolesnika te tijekom i nakon primjene kemoterapije. Enteralna prehrana je fiziološka i jeftinija od parenteralne prehrane te je metoda izbora za hranjenje bolesnika s malignim bolestimaMalnutrition is a common disorder in patients with cancer and. enteral nutrition is an optimal method for the caloric intake in patients with cancer and preserved function of the gastrointestinal system. Enteral nutrition is preserving the function of intestinal mucosa, increasing nutritional intake and the weight gain. The preferences of enteral nutrition versus parenteral nutrition are statistically proven after surgical procedures in oncologic patients and also in patients receiving chemotherapy. The enteral nutrition is more physiological than parenteral, with the proven cost benefit and it is a method of choice for the nutrition of patients with malignant disease

Controversies and dilemmas in the treatment of malignant pain

We analyze, theoretically and by means of molecular dynamics (MD) simulations, the generation of mechanical force by a polyelectrolyte (PE) chain grafted to a plane and exposed to an external electric field; the free end of the chain is linked to a deformable target body. Varying the field, one can alter the length of the non-adsorbed (bulk) part of the chain and hence the deformation of the target body and the arising force. We focus on the impact of added salt on the magnitude of the generated force, which is especially important for applications. In particular, we develop a simple variational theory for the double layer formed near electrodes to compute the electric field acting on the bulk part of the chain. Our theoretical predictions agree well with the MD simulations. Next, we study the effectiveness of possible PE-based nano-vices, comprised of two clenching planes connected by PEs exposed to an external electric field. We analyze a novel phenomenon – two-dimensional diffusion of a nano-particle, clenched between two planes, and introduce a quantitative criterion for clenching efficiency, the clenching coefficient. It is defined as a logarithm of the ratio of the diffusion coefficients of a free and clenched particle. Using first a microscopic counterpart of the Coulomb friction model, and then a novel microscopic model based on surface phonons, with the vibration direction normal to the surface, we calculate the clenching coefficient as a function of the external electric field. Our results demonstrate a dramatic decrease of the diffusion coefficient of a clenched nano-particle for the range of parameters relevant for applications; this proves the effectiveness of the PE-based nano-vices