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Wednesday, July 31, 2013

Paraneoplastic neuropathies.

Source

aService of Neurology, Hospital Clinic, Universitat de Barcelona bInstitut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS) cInstitució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain dDepartment of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Abstract

PURPOSE OF REVIEW:

This review describes relevant advances in paraneoplastic neuropathies with emphasis on particular syndromes and the impact of new therapies.

RECENT FINDINGS:

Sensory neuronopathy may present with symptoms that do not raise the suspicion of a paraneoplastic origin. 
A recent study on sensory neuronopathies of different causes identified paraneoplastic cases in a group of older (>60 years) male patients with subacute onset early pain, and frequent involvement of the arms. Paraneoplastic sensorimotor polyneuropathies may be confused with chronic inflammatory demyelinating polyneuropathy (CIDP) and in lymphomas with direct infiltration of nerves (neurolymphomatosis). 

Recent neurophysiological studies indicate that the polyneuropathy of POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M component, and skin changes) can be differentiated from CIDP by the presence of diffuse demyelination and more severe axonal loss. Neuropathy in Waldenström macroglobulinemia is heterogeneous. Up to 38% have demyelinating features and the rest show axonal degeneration due to different causes (dysimmune, amyloidosis, or tumoral infiltration). Isolated case reports suggest that the combination of cyclophosphamide and rituximab may be effective in paraneoplastic neuronopathies. Lenalidomide and dexamethasone are effective to control the neuropathy of POEMS patients who are not suitable for or progress after autologous stem cell transplantation.

 Curr Opin Neurol. 2013 Jul 25. [Epub ahead of print]

Burn-out en cancérologie

Alerte au burn-out en cancérologie : comment faire face ?


Paris, France - « Le burn-out ou syndrome d'épuisement professionnel est fréquent dans toutes les populations professionnelles, présent dans tous les pays du monde », a indiqué le Dr Roland Behar, psychiatre en oncologie (Hôpital Lariboisière, Paris) au cours d'une session consacrée au burnout en cancérologie lors du congrès Eurocancer 2013 [1].
« Il touche 39% des gens qui travaillent en cancérologie [2,3] », a commenté l'orateur.
Il affecte, par ailleurs, 10% des salariés [4] et 20 à 40 % des soignants [2].
Il est responsable de 3 fois plus de suicides que dans la population générale : 14% chez les médecins libéraux au lieu de 5% dans la population générale [5]. « Un suicide sur 10 est lié à un burn-out », précise le Dr Behar.
Définition du syndrome d'épuisement professionnel
La définition générale est celle d'un épuisement professionnel associé à un engagement professionnel intense, prolongé, aux conditions anxiogènes avec des tensions émotionnelles intenses.
Pour Freudenberger (1974), il s'agit d'un état de fatigue et de frustration causés par dévouement sans réponse aux attentes espérées.

L'oncologie : un terrain propice au burn-out


En oncologie, la charge de travail est intense et prolongée : « ce qui fait le noyau du burn-out ». Le travail demande un haut niveau de technicité. La crainte de faire des erreurs est omniprésente. Le travail est éprouvant sur le plan humain. Le sujet est dans son imaginaire aux confins des notions de handicap, de dégradation physique et de mort. En outre, les soignants dispensent des programmes thérapeutiques agressifs, longs, aléatoires, et imprévisibles sur leurs résultats.
Il y a un lien psychologique croissant qui s'installe au cours du temps entre le patient et le soignant mais il est d'emblée intense. Il y a un rapport de confiance et une notion de responsabilité de la vie d'autrui dans un contexte très anxiogène au quotidien.

Un îlot dépressif isolé dans la vie du patient


Au début, le plus souvent, la pathologie a la caractéristique de n'avoir aucun symptôme clinique. L'installation est discrète et progressive. « Le problème est que la symptomatologie est tellement polymorphe et non spécifique qu'on l'on n'y pense pas d'emblée », explique l'intervenant.
Il s'agit d'un équivalent dépressif qui a des caractéristiques différentes d'un syndrome dépressif classique. Il est électivement orienté sur le sujet du travail dans son contexte particulier. « C'est un ilot dépressif isolé dans la vie du patient. »
La victime de burn-out souffre d'une très grande fatigue physique. Les mouvements deviennent pénibles, les déplacements difficiles, l'absentéisme est croissant. « On peut se déplacer pour aller à n'importe quelle activité mais sur le travail cela devient de plus en plus douloureux », précise le Dr Behar. Ou, à l'inverse, on constate une agitation psychomotrice intermittente.
Il y a un désir de changement de poste, de reconversion alors que la motivation est pourtant réelle et authentique.
Les somatisations sont multiples : cervicalgies, lombalgies, alopécies, céphalées, palpitations, troubles digestifs.
Les troubles du contrôle émotionnel aussi: labilité de l'humeur, larmes, irritabilité, colère aux moindres stimuli.

Apparition d'une « chosification » du patient


Une des deux principales caractéristiques du burn-out en cancérologie est l'apparition de troubles relationnels inter personnels avec une déshumanisation progressive et une « chosification » du patient. « On se sent indisponible pour cette relation personnalisée soignant-malade qui est pourtant souvent la raison qui a déterminé le choix de cette activité. On devient froid, agressif, cynique. On peut même aller jusqu'à faire des erreurs », explique le psychiatre.
Il y a aussi une indisponibilité pour les relations professionnelles, familiales, et sociales.
La personne en burn-out est dépendante économiquement du travail d'où une image dévalorisée d'elle-même et un risque de conduite à risques.
Elle cherche parfois une aide par une conduite addictive : alcool, tabac, médicaments pour « tenir le coup », espérant obtenir une action de détente.

Conséquences : absentéisme ou pseudo-activisme avec perte d'efficience au travail


Les conséquences psychologiques sont les troubles de l'appétit (anorexie, boulimie), les troubles du sommeil (difficultés d'endormissement, réveils nocturnes avec pensées sur le travail, cauchemars sur le thème du travail dans son contexte, levers précoces ou tardifs avec fatigue).
breakthrough pain

Painful boney metastases.

Source

Department of Anesthesiology, Albany Medical College, Albany, New York, USA.

Abstract

Boney metastasis may lead to terrible suffering from debilitating pain.
 The most likely malignancies that spread to bone are prostate, breast, and lung.
Painful osseous metastases are typically associated with multiple episodes of breakthrough pain which may occur with activities of daily living, weight bearing, lifting, coughing, and sneezing.

Almost half of these breakthrough pain episodes are rapid in onset and short in duration and 44% of episodes are unpredictable.

Treatment strategies include:  
analgesic approaches with "triple opioid therapy", bisphosphonates, chemotherapeutic agents, hormonal therapy, interventional and surgical approaches, steroids, radiation (external beam radiation, radiopharmaceuticals), ablative techniques (radiofrequency ablation, cryoablation), and intrathecal analgesics.

KEYWORDS:

boney metastases, breakthrough, cancer, pain, triple opioid therapy
Korean J Pain. 2013 Jul;26(3):223-41. doi: 10.3344/kjp.2013.26.3.223. Epub 2013 Jul 1.
Images from this publication. 

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Breakthrough Pain

Efficacy and Safety of Sublingual Fentanyl Orally Disintegrating Tablets in Patients with Breakthrough Pain: Multicentre Prospective Study.

Source

Department of Anesthesiology, Hospital Plató, c/ Plató 21, 08006, Barcelona, Spain, jordi.guitart@hospitalplato.com.

Abstract

BACKGROUND AND OBJECTIVES:

The aim of this study was to evaluate the effectiveness and safety of sublingual fentanyl oral disintegrating tablets (sublingual fentanyl ODT) for the treatment of breakthrough pain (BTP), cancer or non-cancer related, in terms of relief of pain intensity, adverse events (AEs) and patient satisfaction, and to further examine the clinical and epidemiological profile of patients with BTP in a clinical setting.

METHODS:

A multicentre, prospective, open-label study was conducted in 19 pain units from Catalonia hospitals (Spain) over a 1-month period. Opioid-tolerant adult patients experiencing episodes of BTP intensity >5 on a visual analogue scale (VAS) during the 12-24 h before screening or AEs related to their previous rescue medication for BTP received sublingual fentanyl ODT in the course of routine clinical practice and completed a 30-day study period consisting of five assessment points: days 0 (baseline), 3, 7, 15 and 30. The efficacy was assessed by collecting pain intensity and pain relief data at baseline and at each assessment. AEs were recorded by investigators throughout the study during clinic visits and telephone follow-ups. For all patients, titration was begun with an initial dose of 100 μg. No more than two doses were allowed to treat an episode and patients might wait at least 4 h before treating another BTP episode with sublingual fentanyl ODT. The dose was increased by 100 μg multiples up to 400 μg as needed; and by 200 μg multiples up from 400 to 800 μg, the maximum titration step.

RESULTS:

A total of 182 patients were enrolled and 177 (97.2 %) completed the study: 37 had breakthrough cancer pain (BTcP) and 145 had breakthrough non-cancer pain (BTncP). The mean pain intensity showed a statistically significant improvement at the first assessment point and at all assessments thereafter (p < 0.0001). At the end of the study, the time lag between administration and first effect of sublingual fentanyl ODT was ≤10 min in 69.0 % (60 % BTcP and 71.2 % BTncP). The number of daily BTP episodes decreased in both groups, but it was statistically significant in BTcP. 114 patients (62.64 %) experienced AEs during the study. AEs recorded included nausea, vomiting, somnolence and constipation, and seven (4.49 %) were considered severe. No death or discontinuation was considered related to AEs.

CONCLUSION:

Sublingual fentanyl ODT provided rapid and consistent relief from BTP, both in cancer and non-cancer patients.
 It was well-tolerated and well-accepted by patients in routine clinical practice.

 Clin Drug Investig. 2013 Jul 24.

Cancer pain management in an oncological ward in a comprehensive cancer center with an established palliative care unit.

Source

Anesthesia & Intensive Care and Pain Relief & Palliative Care Unit, La Maddalena Cancer Center, and Palliative Medicine, University of Palermo, Via S. Lorenzo 312, 90145, Palermo, Italy, terapiadeldolore@lamaddalenanet.it.

Abstract

BACKGROUND:

This survey was performed to draw information on pain prevalence, intensity, and management from a sample of patients who were admitted to an oncologic center where a palliative care unit (PCU) has been established for 13 years.

METHODS:

Cross-sectional survey in an oncological department performed 1 day per month for six consecutive months.

RESULTS:

Of the 385 patients, 69.1, 19.2, 8.6, and 3.1 % had no pain, mild, moderate, and severe pain, respectively. Inpatients and patients with a low Karnofsky score showed higher levels of pain intensity (p < 0.0005). One hundred twenty-eight patients with pain or receiving analgesics were analyzed for pain management index (PMI). Only a minority of patients had negative PMI score, which was statistically associated with inpatient admission (p = 0.011). Fifty of these 128 patients had breakthrough pain (BTP), and all of them were receiving some medication for BTP.

CONCLUSION:

It is likely that the presence of PCU team providing consultation, advices, and cultural pressure, other than offering admissions for difficult cases had a positive impact on the use of analgesics, as compared with previous similar surveys performed in oncological setting, where a PCU was unavailable. This information confirms the need of the presence of a PCU in a high volume oncological department.

 Support Care Cancer. 2013 Jul 26.

Educating Men About PSA Tests: Tutorials Do the Job

Nick Mulcahy
Jul 29, 2013
 

Print and Web-based learning tools that men can review at home significantly improve informed decision-making about prostate cancer screening, but they do not affect actual screening rates, according to new study.
Specifically, these tools, known as decision aids, resulted in significantly improved prostate cancer knowledge and reduced "decisional conflict," compared with usual care, at both 1 and 13 months after the aids were used (P < .001).
The results were published online today in JAMA Internal Medicine.
The study is the largest of its kind to date — with 1893 participants — on prostate cancer screening, which comprises both prostate-specific antigen testing and the digital rectal exam, according to the authors, led by Kathryn L. Taylor, PhD, associate professor of population sciences at the Georgetown Lombardi Comprehensive Cancer Center in Washington, D.C.
Whether or not to get screened is a "difficult decision" for men, in part because of the "mixed evidence" about benefits, Dr. Taylor and colleagues explain. It is a decision in need of educational support. "Most men overestimate the benefits of prostate cancer screening and are unaware of its limitations," they write.
These results are "consistent" with the decision-aid literature for both prostate cancer screening decisions and other medical issues — with one exception, said Richard M. Hoffman, MD, MPH, professor of medicine at the University of New Mexico School of Medicine in Albuquerque, who was not involved with the study.
"Although the current study found no effect on screening rates, a previous meta-analysis of 18 studies showed that receiving a decision aid reduced screening by about 12%," Dr. Hoffman told Medscape Medical News in an email.
Decision aids, which are typically reviewed at home by patients, promote efficiency in the clinic, said Dr. Hoffman, who is also a consultant to the Informed Medical Decision Foundation in Boston.
When a patient reviews the material at home, the clinician can then focus "just on a patient's specific questions, rather than trying to review the entire topic," he noted.
Dr. Taylor and colleagues believe that "work is now needed" to deliver decision aids to more men considering prostate cancer screening.
According to Dr. Hoffman, several factors will "improve uptake," including malpractice protection. "Washington state has passed legislation stating that receiving and discussing a decision aid represents the highest level of informed consent," he said.
Clinicians also need reimbursement for the activity. "The healthcare reform act supports engaging patients in shared decision making (best accomplished by providing a decision aid), but clinicians need to be able to bill for this activity," he explained.

Lasting Improvement
In the randomized study, conducted at 3 Washington, DC–based health systems from 2007 to 2011, 628 men received a print decision aid, 625 used a Web-based interactive version of the same aid, and 626 men received usual care (i.e., no information from clinicians). Of the study cohort, 40% was black and 23% had a high school education or less.
At baseline and 1 and 13 months after participants reviewed their decision aid or received usual care, a telephone interview was conducted to assess participant's knowledge of prostate cancer and related screening (18 true/false questions) and their decisional conflict and satisfaction.
As noted above, at each follow-up,the 2 decision aids resulted in significantly better prostate cancer knowledge and less decisional conflict than usual care.
The protracted period of significantly improved knowledge (up to 13 months) is notable, said Dr. Taylor.
"This is a very important finding, given that only 2 other studies have demonstrated the maintenance of knowledge at 1 year," she told Medscape Medical News in an email. "Because men must continually make the decision about whether to be screened over a number of years, it is important that the materials provided information that was retained."
Among the decision-aid users, the maintenance of high satisfaction was another story.
At 1 month, significantly more participants in the print group than in the Web group reported high satisfaction (60.4% vs 52.2%; P = .009), as did significantly more participants in the Web (P = .001) and print (P = .03) groups than in the usual-care group (45.5%).
At 13 months, there was no difference in the proportion of participants reporting high satisfaction between the print and usual care groups (55.7% vs 49.8%; P = .06), or between the print and Web (50.4%) groups (P = .10).
Screening rates at 13 months (around 59%) did not differ significantly among groups.
The study authors contend that decision aids do not bias users in any way.
"The decision aids offer neutrality, shown by the fact that they did not influence the screening decision in either direction compared with usual care.... These tools offer flexibility for patients and providers, given the availability of both print-based and Web-based tools," they conclude.
The study was supported by grants from the National Cancer Institute and the Department of Defense. The authors have disclosed no relevant financial relationships.
JAMA Intern Med. Published online July 29, 2013. Abstract
 DU DIU SOINS PALLIATIFS-FRANCE

http://dudiu.lequotidiendumedecin.fr/index.cfm?fuseaction=recherche&specialite=116
UNIVERSITE BORDEAUX
DIU SOINS PALLIATIFS

http://www.univ-bordeauxsegalen.fr/fr/etudes/catalogue-des-formations/formations-par-type/SDU/MED/diu-soins-palliatifs-et-d-accompagnement.html

http://www.univ-bordeauxsegalen.fr/fr/etudes/catalogue-des-formations/formations-par-type/SDU/MED/diu-soins-palliatifs-et-d-accompagnement.html
Palliat Support Care. 2013 Feb;11(1):47-67.

Cultural and religious considerations in pediatric palliative care.

Source

National Cancer Institute, National Institutes of Health, Bethesda, MD, USA. wienerl@mail.nih.gov

Abstract

OBJECTIVE:

A growing multicultural society presents healthcare providers with a difficult task of providing appropriate care for individuals who have different life experiences, beliefs, value systems, religions, languages, and notions of healthcare. This is especially vital when end-of-life care is needed during childhood. There is a dearth of literature addressing cultural considerations in the pediatric palliative care field. As members of a specific culture often do not ascribe to the same religious traditions, the purpose of this article was to explore and review how culture and religion informs and shapes pediatric palliative care.

METHOD:

Comprehensive literature searches were completed through an online search of nine databases for articles published between 1980 and 2011: PsychINFO, MEDLINE®, Journal of Citation Reports-Science Edition, Embase, Scopus, CINAHL®, Social Sciences Citation Index (SSCI), EBSCO, and Ovid. Key terms included: culture, transcultural, spiritual, international, ethnic, customs or religion AND end-of-life, palliative care, death, dying, cancer, or hospice, and children, pediatrics, or pediatric oncology. Reference lists in the retrieved articles were examined for additional studies that fit the inclusion criteria, and relevant articles were included for review. In addition, web-based searches of specific journals were conducted. These included, but were not limited to: Qualitative Health Research, Psycho-Oncology, Journal of Psychosocial Oncology, Journal of Pediatric Psychology, Journal of Pediatric Health Care, Journal of Pediatric Oncology Nursing, Omega, Social Work in Health Care, and Journal of Palliative Medicine.

RESULTS:

Thirty-seven articles met eligibility criteria. From these, seven distinct themes emerged that have implications for pediatric palliative care.
 These include the role of culture in decision-making, faith and the involvement of clergy, communication (spoken and unspoken language), communicating to children about death (truth telling), the meaning of pain and suffering, the meaning of death and dying, and location of end-of-life care.

SIGNIFICANCE OF RESULTS:

The review of the literature provides insight into the influence of religion and how culture informs lifestyle and shapes the experiences of illness, pain, and end-of-life care. Recommendations for providing culturally sensitive end-of-life care are offered through the framework outlined in the Initiative for Pediatric Palliative Care Quality Improvement Project of 2002.  
Cultural traditions are dynamic, never static, and cannot be generalized to all families. Guidelines to aid in approaches to palliative care are provided, and providers are encouraged to define these important differences for each family under their care.

Furry and Feathered Family Members-

A Critical Review of Their Role in Palliative Care.

Source

1Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, Australia.

Abstract

This article presents a comprehensive critical review of the peer-reviewed literature on palliative care and companion animals (CAs), reporting on the evidence and knowledge base regarding CAs and their role for people at end of life. PubMed, PsycINFO, Medline, Scopus, and Google Scholar were searched for studies pertaining to CAs, end of life, and hospice palliative care. Six studies dealt specifically with empirical research. The remaining literature addressed the topic peripherally or anecdotally. The evidence for efficacy and the knowledge base about the role of CAs at end of life in hospice and palliative care is weak.

 Further efforts are required to study the conditions under which CAs may be beneficial for patient care, including acceptability to staff, family, and other patients, and with consideration of welfare for the animals involved.

 Am J Hosp Palliat Care. 2013 Jul 26. [Epub ahead of print]

Tuesday, July 30, 2013

http://www.cairn.info/revue-infokara-2006-1-page-20.htm
http://www.dialogpalliatif.org
http://www.portail-soins-palliatifs.org
http://www.sfap.org/content/constipation-morphiniques

A cross-sectional study of constipation and laxative use in advanced cancer patients: insights for revision of current practice.

Source

Yan Chai Hospital-Hong Kong Baptist University Clinical Centre for Training and Research in Chinese Medicine (West Kowloon), Hong Kong, SAR, China.

Abstract

PURPOSE:

This study aimed to evaluate the bowel habit and laxative use in advanced cancer patients with constipation in palliative care unit.

METHODS:

It was a cross-sectional study using a self-designed questionnaire.

RESULTS:

A total of 225 patients were analysed. Among all patients, 92.0 % (207 patients) had any intervention for relief of constipation, including laxatives, suppositories, enemas, digital evacuation and Chinese herbal medicine, and 65.3 % (147 patients) were on laxatives prescribed by our doctors. The severity of constipation as assessed by the constipation visual analogue scale (CVAS) (0-7, 7 = most severe) was reported as no constipation (0-1) in 19.6 % of patients, constipation (2-4) in 50.7 % and severe constipation (5-7) in 29.8 %. More patients with severe constipation, as compared with patients with constipation and no constipation, reported inadequate pushing force (83.6 vs. 47.4 vs. 6.8 %), sense of incomplete defecation (40.3 vs. 14.9 vs. 6.8 %) and difficult defecation (58.2 vs. 26.3 vs. 0 %), all p < 0.001, but there was no difference in stool types as assessed by Bristol Stool Scale (p = 0.303). Patients not on opioids, as compared with patients on strong opioids, had similar CVAS scores and description of constipation but had least laxatives prescribed (60.2 vs. 78.9 %, p = 0.012).

CONCLUSION:

Evaluation of constipation should not rely on stool form or consistency alone, and patient's description of constipation is worth consideration. Constipation is also a problem in patients not on opioids and more attention is required.
 A revisit to existing guidelines is needed.

Comment in

Response to "A cross-sectional study of constipation and laxative use in advanced cancer patients: insights for revision of current practise". [Support Care Cancer. 2012]

Support Care Cancer. 2013 Jan;21(1):149-56. doi: 10.1007/s00520-012-1504-x. Epub 2012 Jun 1.

Laxative prescriptions to cancer outpatients receiving opioids: a study from the Norwegian prescription database.

Source

National Competence Centre for Complex Symptom Disorders, Department of Pain and Complex Symptom Disorders, St. Olavs University Hospital, Trondheim, Norway. lars@skollerud.com

Abstract

BACKGROUND:

During opioid treatment of cancer pain, constipation is one of the most prevalent and bothersome side effects. Guidelines suggest that treatment with laxatives should be initiated when opioid therapy is started.

AIM:

This study aims: (1) to determine to what extent patients, starting on opioids due to cancer pain, receive laxatives; (2) to examine the temporal relationship between initiation of opioid therapy and initiation of treatment with laxatives; and (3) to study to which extent the treatment follows current guidelines.

METHODS:

Data from the Norwegian prescription database (NorPD) were used to investigate dispensed prescriptions of laxatives to outpatients in Norway, who are receiving opioids for cancer pain. Data from NorPD cover all dispensed prescriptions of drugs to outpatients, making it possible to follow patients over time. The study cohort was followed from 2005 to the end of 2008.

RESULTS:

Of 2,982 patients who started opioid therapy directly with WHO step III opioids, 1,325 patients (44.4 %) did not receive laxatives during the study period. Only 738 patients (24.7 %) received laxatives at the same time as opioid therapy was initiated. Another 657 patients (22.0 %) received laxatives after their initiation of opioids at some time during the study period.

CONCLUSION:

Of those who started directly on a strong opioid, only one fourth received laxatives concomitantly with the first opioid, and nearly half did not receive laxatives at all. These findings indicate that the current guidelines are not followed.


 Support Care Cancer. 2013 Jan;21(1):67-73. doi: 10.1007/s00520-012-1494-8. Epub 2012 Jun 1.

The prevalence of bowel problems reported in a palliative care population.

Source

Department of Palliative Care, Calvary Mater Newcastle, Waratah, New South Wales, Australia. katherine.clark@calvarymater.org.au

Abstract

CONTEXT:

Constipation and other disturbances of bowel function are distressing problems for people with specialist palliative care needs. Recent observations suggest that such problems may worsen as people become more unwell, but the changes in intensity over time are not well documented.

OBJECTIVES:

The objectives of this work were to understand the prevalence, intensity, and progression of self-reported bowel disturbances across a community palliative care population, which included people with cancer and noncancer diagnoses.

METHODS:

All people referred to a community-based palliative care service over a period of 6.3 years had their bowel problem scores reported, using a numerical rating score at every clinical encounter until their death, at four discrete time points, namely, 90, 60, 30, and seven days before death. This allowed change over three time periods to be considered. At the same time, other symptom scores were collected including nausea, fatigue, pain, appetite problems, and breathing problems. Patients were categorized according to the underlying disease that accounted for their referral to palliative care, namely, cancer diagnoses (upper gastrointestinal cancers, lower gastrointestinal cancers, cancers of the associated digestive organs, and other cancers) and nonmalignant diagnoses. Group differences over the time periods were assessed using analysis of variance. Bivariate analysis was used to explore the relationship between bowel disturbances and other symptoms using Spearman's Rho correlation.

RESULTS:

For 7772 patients, data were collected an average of 22.5 times, generating 174,783 data collection points over an average of 98.6 days on the service. At the time of referral to the service, 3248 (42.4%) people had disturbed bowel scores, 548 (7.2%) of whom described these as severe. Only 1020 (13.1%) people never described disturbed bowel function over their time in palliative care. At each time point, approximately one-third were experiencing disturbed bowel function, with proportionally greater numbers of people experiencing more significant problems as death approached (Χ(2) (9)=119.3; P<0.001). Most referrals to the service were because of cancer diagnoses, with no significant differences noted between the bowel disturbance scores of those with cancer diagnoses compared with those with nonmalignant disease. Associations between bowel problem score and appetite problems, nausea, breathing problems, fatigue, and pain were explored. Although weak, there were statistically significant associations between all symptoms and bowel problem scores except for breathing problems.

CONCLUSION:

In conclusion, disturbed bowel function consistently remains a problem for people under the care of palliative care services, with the proportion of people with severe problems increasing as death approaches. This is despite the time and number of interventions currently used to palliate these problems.

Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.
J Pain Symptom Manage. 2012 Jun;43(6):993-1000. doi: 10.1016/j.jpainsymman.2011.07.015.

Physical activity in patients with advanced-stage cancer: a systematic review of the literature.

Source

School of Nursing, University of Pittsburgh, USA. albrech@pitt.edu

Abstract

The importance of physical activity for chronic disease prevention and management has become generally well accepted. The number of research interventions and publications examining the benefits of physical activity for patients with cancer has been rising steadily. However, much of that research has focused on the impact of physical activity either prior to or early in the cancer diagnosis, treatment, and survivorship process. Research focusing on the effects of physical activity, specifically for patients with advanced-stage cancer and poorer prognostic outcomes, has been addressed only recently. The purpose of this article is to examine the state of the science for physical activity in the advanced-stage disease subset of the cancer population. Exercise in a variety of intensities and forms, including yoga, walking, biking, and swimming, has many health benefits for people, including those diagnosed with cancer. Research has shown that, for people with cancer (including advanced-stage cancer), exercise can decrease anxiety, stress, and depression while improving levels of pain, fatigue, shortness of breath, constipation, and insomnia.

 People diagnosed with cancer should discuss with their oncologist safe, easy ways they can incorporate exercise into their daily lives.

 Clin J Oncol Nurs. 2012 Jun 1;16(3):293-300. doi: 10.1188/12.CJON.293-300.

Advanced cancer patients' self-assessed physical and emotional problems on admission and discharge from hospital general wards--a questionnaire study.

Source

Department of Surgery K, Bispebjerg Hospital, Bispebjeg Bakke 23, Copenhagen, Denmark. lsoe0012@bbh.regionh.dk

Abstract

Most cancer patients receiving life-prolonging or palliative treatment are offered non-specialist palliative services. There is a lack of knowledge about their problem profile. The aim of this article is to describe the incidence of patient-reported physical and emotional problems on admission and discharge from general hospital wards and health staff's reported intervention. A prospective study was undertaken over 12 months, where advanced cancer patients completed a patient questionnaire, EORTC QLQ C15-PAL, on admission (n= 97) and discharge (n= 46). The incidences of the problems were dichotomised in intensity categories. The average number of 'clinically relevant problems' on admission was 5 (SD 2) and on discharge 4 (SD 2). A Wilcoxon signed rank test showed significant change in mean score for six out of nine problem areas, but the majority of the patients did not move to the lower intensity category. The highest concurrence was between patient-reported problems and reported intervention for physical function, pain, constipation and loss of appetite.  

Palliative cancer patients' self-reported problem profile on admission and discharge from hospital has not previously been described and the results indicate a need to focus on improvements to palliative services and for a special service for pain and constipation that could prevent some admissions.

 Eur J Cancer Care (Engl). 2012 Sep;21(5):667-76. doi: 10.1111/j.1365-2354.2012.01342.x. Epub 2012 Mar 27.

Management of opioid-induced constipation

Management of opioid-induced constipation in cancer patients: focus on methylnaltrexone.

Source


Abstract

Opioids are one of the most widely used therapies for the palliative treatment of cancer pain; however, despite their proven analgesic efficacy, they are associated with several adverse effects. Associated with psychological distress and multiple concomitant clinical concerns, constipation is the most commonly occurring adverse effect of chronic opioid therapy in cancer patients. 

Whilst prophylaxis remains the first-line management option, methylnaltrexone is a recommended treatment option for opioid-related constipation if administration of laxatives is ineffective.

 Due to its inability to cross the blood-brain barrier, methylnaltrexone exerts a peripheral inhibition of opioid-related effects without influencing the opioid-induced central effects; as a result, the analgesic effect of opioids is unaffected. Moreover, multiple clinical trials, albeit not always conducted specifically in cancer patients, have demonstrated that up to 4 months' treatment with either intravenous or subcutaneous methylnaltrexone provides effective relief from opioid-related constipation and is well tolerated. 

Preliminary evidence indicates that the addition of methylnaltrexone to standard care for opioid-related constipation may also be advantageous from a pharmacoeconomic perspective. In addition, preliminary data suggest that methylnaltrexone could be associated with some further clinical benefits other than the treatment of opioid-related constipation, such as the improvement of gastric emptying, the relief of nausea/vomiting, and the reduction of the risk of regurgitation and pulmonary aspiration. 

This narrative review examines the most recent evidence and evaluates the current role of methylnaltrexone in the management of opioid-related constipation, and its potential efficacy in cancer patients. The pharmacokinetics, pharmacodynamics, efficacy and tolerability of methylnaltrexone are discussed.

 Emergency Care, Critical Care Medicine, Pain Medicine and Anaesthesiology Department at Tor Vergata Polyclinic, University of Rome-Tor Vergata, Rome, Italy. antonio.gatti@ptvonline.it
 Clin Drug Investig. 2012 May 1;32(5):293-301. doi: 10.2165/11598000-000000000-00000.
http://www.liebertpub.com/jpm

The future of palliative care in the Islamic world

Cancer in the developing world, of which the Islamic world is a substantial component, is characterized by far more advanced stages at diagnosis, fewer allocated resources for prevention and treatment, and higher incidence than in countries with more developed health systems.1
The top five cancers in the emerging world are (in descending order) stomach, lung, liver, breast, and cervix, and in developed countries the most common cancers are those of the lung, colorectum, breast, stomach, and prostate.2 In Indonesia, which has an estimated total cancer incidence of about 300,000 cases per year, only 10% are seen in the health care system.3 Similarly, only one cancer unit is available for about 120 million people in Bangladesh.4 Because preventive and curative services for cancer control are underdeveloped in many Islamic countries, the development of palliative care services is a more realistic option for most patients in these countries who have cancer.
The available health care services in the Islamic world clearly do not meet patients' needs, and there is little sign that this situation will improve in the foreseeable future. Even if palliative care development is placed on an Islamic country's health care agenda, such development might be handicapped by technical and economic constraints. However, despite this gloomy picture, there are signs that palliative medicine is beginning to take off in the Islamic world. For example, the medical use of morphine for cancer pain control has been steadily increasing during the past few years in many Islamic countries.5 Once a palliative care program takes root in an Islamic country, it usually grows into a thriving service.3,6,7,8,9,10

SAUDI ARABIA

In the early 1990s, a group of nurses and physicians at the King Faisal Specialist Hospital in Riyadh, Saudi Arabia, saw that a huge need existed to establish palliative care services for patients with advanced cancer in both the hospital and the community. The group's proposal for the new service was approved, and within a few years the palliative care program developed into a comprehensive service. It now has a 10-bed tertiary care unit, an outpatient clinic, a home care service, an inpatient consultation service, and an outreach clinic that serves patients in three other regions in the country. A recent major development was the establishment of a postgraduate training program where interested physicians spend two years receiving advanced training in palliative care.6,7 I was privileged to be the first physician to join this program. Several other hospitals in Saudi Arabia have recently started to develop local palliative care programs.

EGYPT

The Society for the Management of Pain was founded in Egypt in 1980. A postgraduate training program was subsequently established to equip physicians with advanced knowledge and skills in pain management. Parenteral morphine is locally manufactured whereas oral preparations are imported. One Egyptian experience that could have possible implications for other Muslim communities is the success that Egypt has had in training patients' relatives to care for patients in their homes. A patient's relative is selected as the principal caregiver and is then given basic teaching on the disease and some tips on patient care at home. The home caregiver is provided with a booklet that contains a daily observation sheet, which is completed by the caregiver and reviewed by the health professionals weekly.8

INDONESIA

Indonesia, which has the largest population among Islamic countries, started its palliative care movement in the early 1990s. The establishment of the National Cancer Committee led to the National Cancer Control Program and ultimately to the Cancer Pain Relief and Palliative Care Program.3 The movement progressed from the establishment of committees and organization of scientific conferences to palliative care services that are provided in pilot health institutions. Although weak opioids had long been widely available in the country, oral morphine was not available until 1995, when it started to be used by some referral hospitals.9

TURKEY

Turkey, which has a total annual cancer incidence of about 100,000 cases, started to develop palliative care services 15 years ago. By 1993, the Turkish Society of Algology (established in 1987) became a regular chapter of the International Association for the Study of Pain. The academic activities of the society included publishing a scientific journal, organizing several conferences, publishing and distributing relevant booklets, and incorporating palliative care into the curriculum of medical students. Some medical colleges in Turkey established postgraduate programs in pain management.10

OTHER ISLAMIC COUNTRIES

Some forms of palliative care services exist in other countries including Tunisia, United Arab Emirates, and Pakistan. The scarcity of reports on palliative care programs in different countries throughout the Islamic world makes it difficult to evaluate the status of such care.

CONCLUSIONS

Although the limited resources and the long list of unmet health needs are factors that could hinder the development of palliative care services in the Islamic world, it could be argued that such development is more dependent on genuine commitment than on material resources.11 Other factors might favor a bright future for palliative care in the Islamic world, namely, the culturally-rooted strong family and community support given to patients, the great emphasis that Islam places on caring for the elderly, and the absolute unacceptability of euthanasia by Muslims.12
The future of palliative care in the Islamic world is difficult to predict with any certainty. Whereas the steady progress in palliative care programs is being made in some countries, the underdevelopment or complete lack of services in other regions is of great concern.
Figure 1
Cancer care programs in Bangladesh are lacking in number and scope
Figure 2
Palliative care at King Faisal Specialist Hospital in Riyadh: a model for other Islamic countries

Notes

Competing interests: None declared
Summary points
  • Patients who have cancer in Islamic countries present with more advanced disease than those in countries with more developed health systems
  • Islamic countries also have fewer resources allocated to cancer prevention or cure
  • The development of palliative care services is a more realistic option for most cancer patients in these countries
  • Saudi Arabia, Indonesia, Egypt, and Turkey have begun to develop palliative care programs and to train health care professionals in pain management
  • The development of palliative care programs in some countries is cause for optimism, but the lack of services in other regions is of great concern

References

1. Stjernsward J, Teoh N. Current status of the Global Cancer Control Program of the World Health Organization. J Pain Symptom Manage 1993;8: 340-347. [PubMed]
2. Jones SB. Cancer in the developing world: a call to action. BMJ 1999;319: 505-508. [PMC free article] [PubMed]
3. Lickiss JN. Indonesia: status of cancer pain and palliative care. J Pain Symptom Manage 1993;8: 423-424. [PubMed]
4. Aranda S. Global perspectives on palliative care. Cancer Nurs 1999;22: 33-39. [PubMed]
5. Joranson DE. Availability of opioids for cancer pain: recent trends, assessment of system barriers, new World Health Organization guidelines, and the risk of diversion. J Pain Symptom Manage 1993;8: 353-360. [PubMed]
6. Gray AJ, Ezzat A, Volker S. Developing palliative care services for terminally ill patients in Saudi Arabia. Ann Saudi Med 1995;15: 370-377. [PubMed]
7. Isbister WH, Bonifant J. Implementation of the World Health Organization “analgesic ladder” in Saudi Arabia. Palliat Med 2001;15: 135-140. [PubMed]
8. Tawfik MO. Egypt: status of cancer pain and palliative care. J Pain Symptom Manage 1993;8: 409-411. [PubMed]
9. Soebadi RD, Tejawinata S. Indonesia: status of cancer pain and palliative care. J Pain Symptom Manage 1996;12: 112-115. [PubMed]
10. Erdine S. Turkey: status of cancer pain and palliative care. J Pain Symptom Manage 1996;12: 139-140. [PubMed]
11. Grossman SA. United States: status of cancer pain and palliative care. J Pain Symptom Manage 1993;8: 437-439. [PubMed]
12. Hosking M, Whiting G, Brathwate C, Fox P, Boshoff A, Robbins L. Cultural attitudes towards death and dying: a South African perspective. Palliat Med 2000;14: 437-439. [PubMed]
 
 West J Med. 2002 January; 176(1): 60–61.
PMCID: PMC1071657
http://muhc.ca/newsroom/article/new-palliative-care-unit-montreal-general-hospital

Soins Palliatifs Namur-BELGIQUE

http://www.foyersaintfrancois.be

comité éthique HDF beyrouth LIBAN

http://www.hdf.usj.edu.lb/files/etique.html

Treatment of constipation

Pharmacological treatment of constipation in palliative care. Clemens KE, Faust M, Jaspers B, Mikus G. SourceClinic of Palliative Medicine, MediClin Robert Janker Klinik, Germany. elina.clemens@mediclin.de Abstract PURPOSE OF REVIEW: The prevalence of constipation in palliative care patients varies. There is uncertainty about the choice from varying recommendations for pharmacological management of constipation and a varying clinical practice in palliative care settings. The purpose of the review was to evaluate the current recommendations of therapy guidelines and to determine the effectiveness and safety of laxative administration for the management of constipation in palliative care patients. RECENT FINDINGS: Despite the clinical importance, there are limited data on the efficacy and safety of laxatives in palliative care patients. The social acceptability varies from country to country, but overall, oral laxatives should, where possible, be used in preference. Systemic opioid antagonists, such as naloxone and methylnaltrexone have been studied in few clinical trials. There is a paucity of well designed, prospective, randomized controlled trials with large enough numbers of patients suffering from constipation and treated with pharmacological methods. SUMMARY: There are limited data available on the conventional pharmacological treatment of constipation in palliative care patients due to insufficient randomized controlled trials. However, subcutaneously administered methylnaltrexone was found to be effective in aiding of laxation and well tolerated with limited or transient side effects in palliative care patients. Curr Opin Support Palliat Care. 2013 Jun;7(2):183-91.

Management of Constipation

Management of Constipation Evidence about the pharmacological management of constipation, part 2: implications for palliative care. Pitlick M, Fritz D. SourceSt. Louis College of Pharmacy, St. Louis, MO, USA. deborah.fritz@va.gov Abstract Constipation remains a challenging problem for patients and caregivers in home healthcare. Part 1 of this two-part series discussed the scope, physiology, and evidence-based practice for nonpharmacological interventions for constipation. This second article will focus on evidence-based pharmacological prevention and management of constipation, medication cost, and implications for palliative care. Home Healthc Nurse. 2013 Apr;31(4):207-18.
Effects of the hospital-based palliative care team on the care for cancer patients: An evaluation study. Kao CY, Hu WY, Chiu TY, Chen CY. SourceDepartment of Nursing, University of Melbourne, Melbourne, Australia. Abstract BACKGROUND: The hospital-based palliative care team model has been implemented in most Western countries, but this model is new in Taiwan and there is little research to evaluate its outcomes. OBJECTIVES: The purpose of this study was to evaluate the effects of the hospital-based palliative care team on the care for cancer patients. DESIGN: The design was a quasi-experimental study with a pretest-posttest design. SETTING: A medical center, National Taiwan University Hospital in Taipei, Taiwan. PARTICIPANTS: Cancer patients were excluded after the hospital-based palliative care team visited if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24h or would be discharged within 24h, or could not communicate in Mandarin or Taiwanese. A sample of 60 patients who consulted the hospital-based palliative care team was recruited. METHODS: Patients recruited to the study were divided to receive the usual care only (control group, n=30) or the usual care plus visits from the hospital-based palliative care team (intervention group, n=30). Data were collected using questionnaires including the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale at the initial assessment and one week later. RESULTS: Comparison between groups revealed that the degree change for edema, fatigue, dry mouth, abdominal distention, and spiritual well-being in the intervention group showed significant improvement compared to the control group (p<0.05). However, there was no difference between groups on measures of anxiety, depression and feeling of social support. Within group analysis showed patients' pain score, dyspnea, and dysphagia improved in both groups (p<0.05). In addition, the average degree of constipation and insomnia in the control group declined from baseline (p<0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p<0.05). CONCLUSION: The findings indicated the hospital-based palliative care team can improve the care for patients in relation to symptom management and spiritual well-being. The hospital-based palliative care team is a good care model for patients and worth implementing in clinical practice in Taiwan. The results also provide a general understanding about how the hospital-based palliative care team works in Taiwanese culture. Int J Nurs Stud. 2013 Jun 20. Copyright © 2013 Elsevier Ltd. All rights reserved.

Monday, July 29, 2013

http://www.association-pierre-clement.fr/notre-association/buts-et-objectifs/
http://www.soinspalliatifs-alsace.fr

http://www.balsam-lb.org/
http://www.apsp-paca.net/bouches-du-rhone.php
http://www.soignantenehpad.fr/pages/themes-de-soin/soins-palliatifs-en-maison-de-retraite/
http://www.chu-brest.fr/les-soins-paliatifs
http://www.chu-rennes.fr/sections/patients/les_soins_palliatifs

Effects of Prophylactic Subcutaneous Fentanyl on Exercise-Induced Breakthrough Dyspnea in Cancer Patients: A Preliminary Double-Blind, Randomized, Controlled Trial.

Source

Department of Palliative Care and Rehabilitation Medicine, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA. Electronic address: dhui@mdanderson.org.

Abstract

CONTEXT:

Dyspnea is one of the most distressing symptoms in patients with cancer, and often worsens with breakthrough episodes on exertion. We hypothesized that fentanyl given prophylactically may alleviate breakthrough dyspnea.

OBJECTIVES:

To determine the feasibility of conducting a randomized trial of subcutaneous fentanyl in patients with cancer, and examine the effects of fentanyl on dyspnea, walk distance, vital signs, and adverse events.

METHODS:

In this double-blind, randomized, controlled trial, we asked ambulatory patients with breakthrough dyspnea to perform a baseline six minute walk test (6MWT), and then assigned them to either subcutaneous fentanyl or placebo 15 minutes before a second 6MWT. We documented the change in dyspnea Numeric Rating Scale (NRS) score, walk distance, vital signs, and adverse events between the first and second 6MWT.

RESULTS:

A total of 20 patients were enrolled (1:1 ratio) without attrition. Comparison between baseline and second walk showed that fentanyl was associated with significant improvements in dyspnea NRS score at the end of the 6MWT (mean [95% CI] -1.8 [-3.2, -0.4]), dyspnea NRS score at rest of 15 minutes after drug administration (-0.9 [-1.8, -0.04]), Borg Scale fatigue score at the end of the 6MWT (-1.3 [-2.4, -0.2]), 6MWT distance (+37.2m [5.8, 68.6]), and respiratory rate (-2.4 [-4.5, -0.3]). Nonstatistically significant improvements also were observed in the placebo arm, with no difference between the two study arms. No significant adverse effects were observed.

CONCLUSIONS:

Prophylactic fentanyl was safe and improved dyspnea, fatigue, walk distance, and respiratory rate. We also observed a large placebo effect. Our results justify larger randomized controlled trials with higher fentanyl doses (clinicaltrials.gov registration: NCT01515566).


Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

 J Pain Symptom Manage. 2013 Jul 3.