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PUBBLICAZIONI TOP ABSTRACT |
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1: Am J Ther. 2005 Jan-Feb;12(1):80-91.
The role of paracetamol in chronic pain: an evidence-based approach.
Nikles CJ, Yelland M, Del Mar C, Wilkinson D.
1Discipline of General Practice, The University of Queensland, Herston, Queensland, Australia; 2Bond University, Gold Coast, Queensland, Australia; 3School of Medicine, The University of Queensland, Herston, Queensland, Australia.
Chronic pain is a significant public health burden. Several international guidelines and influential reviews recommend the use of paracetamol (acetaminophen) as the first-line analgesic of choice for the management of chronic pain. These recommendations are based largely on the balance of evidence, which favorably demonstrates the efficacy, safety, and low cost of paracetamol relative to other analgesics.A decade ago, March et al suggested that because of the dangers associated with conventional nonsteroidal antiinflammatory (NSAID) use, particularly in the elderly, they should ideally not be used without an individual n-of-1 trial to show that they are more effective than paracetamol. Today, the results of our investigations into the individualization of pain management options continue to support this suggestion. Based on the data available to date, it still seems prudent to use NSAIDs only in those patients in whom there is good evidence of improved efficacy over paracetamol. In patients wi th chronic pain, paracetamol can play an important role as an NSAID sparer, with resultant benefits in terms of reduced adverse effects and cost savings.
2: Intern Med J. 2005 Jan;35(1):39-44.
Prospective audit of short-term concurrent ketamine, opioid and anti-inflammatory ('triple-agent') therapy for episodes of acute on chronic pain.
Good P, Tullio F, Jackson K, Goodchild C, Ashby M.
Department of Medicine, Southern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University and Medicine Program, Southern Health, McCulloch House, Monash Medical Centre, Melbourne, Victoria, Australia.
Aim: This prospective audit was undertaken in order to document the analgesic response and adverse effects of concurrent short-term ('burst') triple-agent analgesic (ketamine, an opioid and an anti-inflammatory agent - either steroidal or non-steroidal) administration, for episodes of acute on chronic pain. The clinical hypothesis in this study is that better pain control may be obtained by simultaneous multiple target receptor blockade. Method: The response of 18 patients is reported. The pain and analgesic requirement data for the 24 h before starting triple-agent therapy were compared with the last 24 h on the triple-agent therapy. Patients were then classified as responders or non-responders. Results : According to stringent clinical criteria, 12 out of the 18 patients were classified as responders. The response rate was highest for somatic pain (7/9) and appeared to decrease with duration of prior uncontrolled pain. Only four out of the 18 patients reported adverse effects and all of these were minor. Conclusions : The results suggest that this 'burst' triple-agent approach is safe and effective in an inpatient palliative care population during episodes of poorly controlled acute on chronic pain, and warrants further investigation to ascertain whether it gives superior results compared to the 'gold-standard' WHO ladder approach. (Intern Med J 2005; 35: 39-44).
3: J Palliat Med. 2005 Feb;8(1):49-57.
Parenteral ketamine as an analgesic adjuvant for severe pain: development and retrospective audit of a protocol for a palliative care unit.
Fitzgibbon EJ, Viola R.
University of Ottawa Institute of Palliative Care, Ottawa. Ontario, Canada.
Background: Ketamine is an effective analgesic agent for treating a variety of neuropathic and cancer pain syndromes. Recent studies indicate that ketamine may have a particular role in the management of patients with neuropathic and/or pain syndromes that are poorly responsive to opioids. Objective: To develop, implement, and subsequently assess a protocol designed to maximize the analgesic effect of ketamine while minimizing its side effects. Design: A retrospective chart audit of 16 patients who had used the ketamine protocol over a 12-month period. Criteria for assessing the effectiveness of ketamine were defined. Results: Ketamine was an effective, well-tolerated analgesic adjuvant for 11 of 16 patients with previously uncontrolled pain. Pain scores were reduced by at least 4 of 10 in 15 of the 16 patients. Median opioid dose reduction on starting ketamine was 25%. Conclusion: The audit confirmed the safety and effectiveness of ketamine as an analgesic adjuvant for patients with severe pain. Baseline opioid dose reduction and prophylactic use of haloperidol or benzodiazepine were effective in minimizing psychotomimetic side effects.
4: Gan To Kagaku Ryoho. 2004 Dec;31 Suppl 2:190-3.
Home palliative care--2 case reports: a long-term cancer pain management with transdermal fentanyl
Fujimoto M, Sakuyama T, Mizutani Y, Kuroda T, Yanaga K.
Dept. of Surgery, The Jikei University School of Medicine.
Transdermal Fentanyl was released in March 2002 in Japan after the acceptance of the insurance under the office of public health. Transdermal therapy is especially effective for patients having difficulty of oral intakes, and for home care cancer patients who suffer from chronic pain only if the therapy is feasible on the long-term basis. We report our cases for long-term cancer pain management with transdermal fentanyl. A total of 52 long-term patients with chronic cancer pain (28 men and 24 women with an average age of 63.5 years, range 46-74 years) were evaluated. The most prevalent cancers were colorectum (n=14), stomach (n=10), breast (n=8), esophagus (n=6), pancreas (n=6), and others. The duration of the transdermal therapy varied from minimum of 2 days to maximum of 630 days. Two patients on this therapy were longer than 500 days. The transdermal therapy was discontinued 2-37 days for 8 patients due to uncontrolled pain relief. Case report 1: A 72-year-old woman suffering from a relapse of pancreatic cancer with chronic back pain experienced a good pain relief after switching from 60 mg/day sustained oral release morphine to 2.5 mg transdermal fentanyl. During the long-term treatment, the transdermal fentanyl dosage had to be increased. Transdermal therapy was continued until the patient's death on day 601. The last fentanyl dosage was 7.5 mg. Transdermal therapy was given 319/601 days at home and 282/601 days in the hospital. Meanwhile, a little rescue suppository morphine was used as an adjuvant during the duration of transdermal therapy. Case report 2: A 73-year-old man suffered a relapse of rectal cancer. He experienced adequate pain relief with 40 mg oral sustained release morphine, but he was switched to 2.5 mg transdermal fentanyl. Transdermal therapy was continued until today on day 630. At present, fentanyl dosage is 20 mg. The patient has been treated at home for 622/630 days. He was hospitalized only once for 8 days because of dehydrations, and has been treated at home. Only a little rescue powder morphine was needed as an adjuvant during the duration of transdermal therapy. In these 2 cases of long-term cancer pain management, transdermal therapy has resulted in good pain reduction and the side effects with transdermal therapy were not noted. Transdermal fentanyl can be recommended for treatment of palliative cancer pain at home.
5: J Palliat Med. 2005 Feb;8(1):20-5.
Sedation for terminally ill patients with cancer with uncontrollable physical distress.
Kohara H, Ueoka H, Takeyama H, Murakami T, Morita T.
Palliative Care Unit, National Sanyo Hospital, Yamaguchi, Japan., Department of Internal Medicine, National Sanyo Hospital, Yamaguchi, Japan.
Background: Relief of distressful symptoms in terminally ill patients with cancer is of prime importance. Use of sedation to accomplish this has been the focus of recent medical studies in countries other than Japan. We investigated the influence on consciousness of sedative drugs in a Japanese hospice. Design and subjects: We defined sedation as medical procedure to decrease level of consciousness in order to relieve severe physical distress refractory to standard interventions. We excluded increases in doses of morphine or other analgesic drugs resulting in secondary somnolence from the present study. We reviewed medical records of patients receiving sedation among 124 consecutive patients admitted to our palliative care unit between January and December in 1999. Results: The 63 patients who received sedation (50.3%) died an average of 3.4 days after its initiation. Major symptoms requiring sedation were dyspnea, general malaise/restlessness, pain, agitation, and nausea/vomiting. The Palliative Performance Status (PPS) just before sedation was 20 or less in 83% of patients. Drugs administered for sedation were midazolam, haloperidol, scopolamine hydrobromide, and chlorpromazine. During the few days before death, sedated patients were significantly more drowsy and less responsive than that in those receiving non-sedative treatment. Conclusions: Our data suggest the effectiveness of sedation in relieving severe, refractory physical symptoms in terminally ill Japanese patients with cancer. Further investigation to confirm safety and effectiveness of sedation in this context is warranted.
6: Sex Transm Infect. 2005 Feb;81(1):5-14.
Does palliative care improve outcomes for patients with HIV/AIDS? A systematic review of the evidence.
Harding R, Karus D, Easterbrook P, Raveis VH, Higginson IJ, Marconi K.
Correspondence to:Dr Richard Harding.
BACKGROUND: The need for palliative care in HIV management is underlined by the high prevalence of pain and symptoms, the toxicity, side effects, and virological failure associated with antiretroviral therapy, emergence of co-morbidities, continued high incidence of malignancies, late presentation of people with HIV disease, and the comparatively higher death rates among the infected individuals. METHODS: A systematic review was undertaken to appraise the effect of models of palliative care on patient outcomes. A detailed search strategy was devised and biomedical databases searched using specific terms relevant to models of palliative care. Data from papers that met the inclusion criteria were extracted into common tables, and evidence independently graded using well described hierarchy of evidence. RESULTS: 34 services met the inclusion criteria. Of these, 22 had been evaluated, and the evidence was graded as follows: grade 1 (n = 1); grade 2 (n = 2); grade 3 (n = 7); grade 4 (n = 1); qualitative (n = 6). Services were grouped as: home based care (n = 15); home palliative care/hospice at home (n = 7); hospice inpatient (n = 4); hospital inpatient palliative care (n = 4); specialist AIDS inpatient unit (n = 2); and hospital inpatient and outpatient care (n = 2). The evidence largely demonstrated that home palliative care and inpatient hospice care significantly improved patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing. CONCLUSIONS: Although the appraisal of evidence found improvements across domains, the current body of evidence suffers from a lack of (quasi) experimental methods and standardised measures. The specialism of palliative care is responding to the clinical evidence that integration into earlier disease stages is necessary. Further studies are needed to both identify feasible methods and evaluate the apparent beneficial effect of palliative care on patient outcomes in the post-HAART era.
7: J Palliat Med. 2005 Feb;8(1):121-35.
Evaluation of the Missoula-VITAS Quality of Life Index-Revised: Research Tool or Clinical Tool?
Schwartz CE, Merriman MP, Reed G, Byock I.
QualityMetric Incorporated, Waltham, Massachusetts., Health Assessment Lab, Waltham, Massachusetts., Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts., DeltaQuest Foundation, Inc., Concord, Massachusetts.
Background: Quality of life (QOL) is a central outcome measure in caring for seriously ill patients. The Missoula-VITAS Quality of Life Index (MVQOLI) is a 25-item patient-centered index that weights each of five QOL dimensions (symptoms, function, interpersonal, wellbeing, transcendence) by its importance to the respondent. The measure has been used to assess QOL for hospice patients, and has been found to be somewhat complex to use and analyze. Objective: This study aimed to simplify the measure, and evaluate the reliability and validity of a revised version as either a research or clinical tool (i.e., "psychometric" versus "clinimetric"). Design: Two data collection efforts are described. The psychometric study collected QOL data from 175 patients at baseline, 3-5 days, and 21 days later. The implementation study evaluated the feasibility and utility of the MVQOLI-R during over six weeks of use. Setting/subjects: End-stage renal patients on dialysis, hospice, or long-term care patients participated in the psychometric study. The implementation study was done in hospice, home health, and palliative care settings. Measurements: The MVQOLI-R and the Memorial Symptom Assessment Scale. Results: The psychometric and implementation studies suggest that the MVQOLI-R performs well as a clinical tool but is not powerful as an outcome research instrument. The MVQOLI-R has the heterogeneous structure of clinimetric tools, and demonstrated both relevance and responsiveness. Additionally, in a clinical setting the MVQOLI-R was useful therapeutically for stimulating communication about the psychosocial and spiritual issues important to the tasks of life completion and life closure. Conclusions: The MVQOLI-R has clinical utility as a patient QOL assessment tool and may have therapeutic utility as a tool for fostering discussion among patients and their clinicians, as well as for helping patients identify sources of suffering and opportunities during this time in their lives.
8: Int J Radiat Oncol Biol Phys. 2004 Dec 1;60(5):1373-8.
Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis from prostate cancer.
Konski A.
Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA. a_konski@fccc.edu
BACKGROUND: To evaluate the various treatments for patients with hormone-refractory prostate cancer with bone metastases using a Markov model. METHODS AND MATERIALS: The base case to be evaluated was of a man with hormone-refractory prostate cancer. The evaluated palliative treatments were pain medication only, chemotherapy consisting of mitoxantrone and prednisone, and single- and multifraction radiotherapy (RT). A literature search was used to generate the transition probabilities and patient utilities. Modeling was used to generate the cost estimates. Expert opinion was used to generate utilities and cost estimates in the absence of literature data. Second-order Monte Carlo simulation produced incremental cost-effectiveness scatterplots and 95% confidence ellipses. RESULTS: Pain medication had the least expected mean cost of all the treatment options at 11,700 US dollars but also the second lowest quality-adjusted survival at 5.75 quality-adjusted life months. Chemotherapy had the highest expected mean cost, 15,300 US dollars, but the lowest quality-adjusted life months (4.93). Incremental cost-effectiveness analysis revealed that single-fraction RT was the most cost-effective treatment, with a cost of 6,857 US dollars/quality-adjusted life year; multifraction RT had an incremental cost-effectiveness ratio of 36,000 US dollars/quality-adjusted life year. Chemotherapy was dominated by pain medication. CONCLUSION: Within the limits of the established model, single-fraction RT was the most cost-effective palliative treatment compared with pain medication, chemotherapy, and multifraction RT. The use of this model allowed comparison of different treatment regimens that could never be evaluated together in a randomized clinical trial. |
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