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Biomedical subjects

Declan Walsh

Publications and source records attributed to Declan Walsh.

At least 37 records · Page 2Linked to original sources
PubMed2004

Cancer pain: how to measure the fifth vital sign.

Pain assessment is essential to good pain management and quality assurance. A pain-rating scale should be used, in combination with a thorough history and a general physical examination. Radiologic studies are an ancillary component rather than a substitute for this process. Outpatient pain diaries and hospital recordings of pain severity with the vital signs facilitate communication. Part of the goal should be to improve function and quality of life.

Humans↗
PubMed2003

Dangerous nutrition? Calcium, vitamin D, and shark cartilage nutritional supplements and cancer-related hypercalcemia.

The use of nutritional supplements in the general population and in cancer patients has become very popular. These supplements are not perceived as medications and are presumed to be safe by cancer patients, who may however be at risk for hypercalcemia. We note that many of our patients who have developed symptomatic hypercalcemia were taking vitamin D, calcium, or shark cartilage supplements. We report eight cases of hypercalcemia in cancer patients seen at the Cleveland Clinic Foundation in whom these nutritional supplements may have contributed to the prevalence or severity of hypercalcemia.

Aged↗
PubMed2003

Mirtazapine for pruritus.

Pruritus is a relatively rare but distressing symptom associated with cholestasis, renal failure, and malignancies. Medical management recently has included the use of ondansetron and paroxetine. We report four patients whose pruritus responded to mirtazapine.

Aged↗
PubMed2003

Opioids in cancer pain: common dosing errors.

Many individuals with advanced malignancy continue to suffer from pain and, consequently, impaired quality of life. The clinical scenarios in advanced cancer pain are complex, and successful management may require a more sophisticated and individualized approach than suggested by the World Health Organization guidelines. In patients referred to the Harry R. Horvitz Center for Palliative Medicine in Cleveland, numerous commonly occurring errors in opioid use have been noted. This article describes these errors and offers strategies with which to improve outcomes for patients suffering with cancer pain.

Analgesics, Opioid↗
PubMed2002

Normal-release and controlled-release oxycodone: pharmacokinetics, pharmacodynamics, and controversy.

Oxycodone has become one of the most popular opioids in the United States. It is superior to morphine in oral absorption and bioavailability, and similar in terms of protein binding and lipophilicity. Gender more than age influences oxycodone elimination. Unlike morphine, oxycodone is metabolized by the cytochrome isoenzyme CYP2D6, which is severely impaired by liver dysfunction. Controlled-release (CR) oxycodone has become one of the most frequently utilized sustained-release opioids in the United States. Both its analgesic benefits and its side effects are similar to those of CR morphine. CR oxycodone is similar to morphine and other opioids in its abuse potential. Deaths attributable to oxycodone are usually associated with polysubstance abuse in which oxycodone is combined with psychostimulants, other opioids, benzodiazepines or alcohol. Oxycodone's kappa receptor binding has little role in abuse or addiction. The cost of CR oxycodone is prohibitive for most American hospices.

Adult↗
PubMed2002

Autonomic nervous system dysfunction in advanced cancer.

The autonomic nervous system (ANS) innervates every organ in the body and is largely involuntary. There have been reports of autonomic dysfunction in cancer patients, but most are case reports. There are suggestions that this abnormality may be common in advanced cancer. Inpatients and outpatients with advanced cancer were enrolled. Patients were excluded if they had a previous diagnosis of a disease associated with autonomic nervous system (ANS) abnormalities, or had taken or were taking drugs affecting the ANS. Autonomic function was evaluated using five bedside cardiovascular tests: (1) heart rate response to deep breathing, (2) heart rate response to standing, (3) heart rate response to the Valsalva maneuver, (4) blood pressure response to standing and (5) blood pressure response to static exercise. Each test result was scored according to a validated scale of 0,.5, or 1. The individual scores were added together and each patient received a dysfunction score: none ( = 0-1), mild ( = 1.5-2), moderate ( = 2.5-3) or severe ( = 3.5-5). Twenty-eight men and 22 women participated, median age was 64 years. The median ECOG performance status was 2. Lung and prostate cancer were the most common ( N = 9, 5). 245 tests were performed; 86 (35%) individual tests were normal or borderline. Composite dysfunction scores were calculated; all the participants had a score consistent with abnormality. The median number of symptoms was 6 (range 1-15). Twenty-eight rated at least one symptom as severe (median 2, range 0-5), but symptoms did not correlate with test abnormalities. The results reveal significant ANS dysfunction in advanced cancer. There are more invasive tests that may give more accurate descriptions of ANS abnormalities in this population. These tests may help define the lesion better than these simple bedside tests. Further research with sophisticated ANS testing is needed to clearly define this paraneoplastic syndrome.

Aged↗
PubMed2002

Established and potential therapeutic applications of cannabinoids in oncology.

Cannabis occurs naturally in the dried flowering or fruiting tops of the Cannabis sativa plant. Cannabis is most often consumed by smoking marihuana. Cannabinoids are the active compounds extracted from cannabis. Recently, there has been renewed interest in cannabinoids for medicinal purposes. The two proven indications for the use of the synthetic cannabinoid (dronabinol) are chemotherapy-induced nausea and vomiting and AIDS-related anorexia. Other possible effects that may prove beneficial in the oncology population include analgesia, antitumor effect, mood elevation, muscle relaxation, and relief of insomnia. Two types of cannabinoid receptors, CB1 and CB2, have been detected. CB1 receptors are expressed mainly in the central and peripheral nervous system. CB2 receptors are found in certain nonneuronal tissues, particularly in the immune cells. Recent discovery of both the cannabinoid receptors and endocannabinoids has opened a new era in research on the pharmaceutical applications of cannabinoids. The use of cannabinoids should be continued in the areas indicated, and further studies are needed to evaluate other potential uses in clinical oncology.

Affect↗
PubMed2002

Assessment of nutritional status and prognosis in advanced cancer: interleukin-6, C-reactive protein, and the prognostic and inflammatory nutritional index.

The Prognostic Inflammatory Nutritional Index (PINI) is a simple scoring system that has been used to evaluate nutritional status and prognosis in critically ill patients. The PINI has never been evaluated in advanced cancer. Fifty consecutive patients with advanced cancer, weight loss, and anorexia were studied. C-reactive protein (CRP), albumin, pre-albumin, interleukin-6 (IL-6), and alpha 1-acid glycoprotein (AAG) were evaluated. The individual values for AAG, CRP, and IL-6 were markedly elevated. In contrast to albumin and prealbumin, CRP levels were very high. The PINI was significantly elevated, and higher than reported in critically ill intensive care patients. Elevated IL-6 levels correlated with high PINI and CRP values. CRP, IL-6, and PINI should be considered in future research on nutritional status and prediction of prognosis in advanced cancer.

Aged↗
PubMed2002

Diazepam as an adjuvant analgesic to morphine for pain due to skeletal muscle spasm.

Side effects of morphine are common when it is given in titrated doses to control severe pain in advanced cancer. We describe a case of severe back pain resistant to parenteral morphine accompanied by muscle spasm, in which the addition of diazepam both had an opioid-sparing effect and provided superior symptomatic relief. Diazepam appears to have a specific role as an adjuvant analgesic for pain due to skeletal muscle spasm associated with painful vertebral metastases.

Back Pain↗
PubMed2002

Cancer and chemotherapy-related upper gastrointestinal symptoms: the role of abnormal gastric motor function and its evaluation in cancer patients.

Disorders of gastric emptying are being increasingly recognized as the basis for "functional" symptoms in the general population. Recent research suggests that abnormal gastric emptying may also be the cause of common gastrointestinal problems in those with cancer, and can be a complication both of the disease and of its treatment. These disorders are diagnosed by measuring the rate of gastric emptying and comparing it with the normal rate. There are numerous methods of measurement available, each with inherent advantages and disadvantages. Differences in method application and a lack of standardization limit the extent to which results from different institutions can be compared. Because of the limitations of existing methods, new technology is frequently being evaluated. Radionuclide measurement is the current method of choice.

Acetaminophen↗
PubMed2002

Long-term rectal administration of high-dose sustained-release morphine tablets.

Two proprietary sustained-release morphine tablets for oral administration are available in the USA, and the authors have found that rectal administration of these provide excellent analgesia although their use by this route is not approved by the United States Food and Drug Administration. An illustrative case in a 72-year-old patient with prostate cancer is reported.

Administration, Rectal↗
PubMed2002

The impact of a palliative medicine consultation service in medical oncology.

This prospective study of consecutive patients describes the palliative medicine consult service in a tertiary level cancer center and its impact on patient care. All inpatients/outpatients referred to the Palliative Medicine Program in a 4-month period were enrolled. Data were collected at the initial consultation using standardized forms with spaces for: reason for the consultation, referring service, demographics and history, ECOG performance status, symptoms, prognosis and diagnostic tests, treatment, and care plan. In all, 240 patients were seen: 79% were referred for symptom management; 53% were referred from medical oncology; and 50% were women. Median patient age was 67 years (range 18-96). Median performance status was 2 (1-4). Most (84%) of the patients had cancer. The cancer sites were: lung in 26% of cases, colorectal in 8%, and breast in 7%. Inpatients accounted for 53% and outpatients, for 47% of the study population. The median number of symptoms per patient was 13 (2-30). The estimated survival was <2 weeks in 15%, 2-8 weeks in 38%, 2-6 months in 37%, and >6 months in 10%. The patients' goals were: improve symptoms for 84%, return home for 55%, and no further admissions for 5%. The support systems named by patients were: family in 89%, friends in 13%, and the community in 5%. Hospice care was discussed at the consultation with 38% of the patients, would have been inappropriate for 31%, was not discussed with 22%, and had been discussed before with 9%. In response to questions about psychosocial care, a caregiver was identified by 78%, a spokesperson by 75%, and durable power of attorney was referred to by 21%. The DNR status was discussed on consult by 57%, had already been discussed with 30%, and was not discussed with 13%. Plan of care foresaw outpatient follow-up for 40%, inpatient follow-up for 32%, and transfer to palliative medicine for 27%. In 39% of cases the consults were considered late referrals. New medications suggested were opioids for 46% of patients, antiemetics for 28%, a bowel regimen for 24%, steroids for 15%, and others for 51%. (1) Palliative medicine consultation involves common complex medical, psychological, and social problems. (2) Complex symptomatology in this population is confirmed. (3) Multiple interventions were suggested even at the initial consultation. (4) Important issues such as DNR (do not resuscitate) status, support system, treatment goals, and eligibility for hospice care had often not been addressed.

Adolescent↗
PubMed2002

Symptoms and prognosis in advanced cancer.

As death from cancer approaches, the associated symptoms become more important. Not only do these symptoms impair quality of life and guide palliative management of the patient, but some also appear to have prognostic value in determining clinical course and survival. A comprehensive prospective analysis of symptoms in 1,000 patients on initial referral to the Palliative Medicine Program of the Cleveland Clinic was conducted. Data were evaluated to determine any relationship between demographic characteristics, symptoms and subsequent survival. Shorter survival after referral to the Palliative Medicine Program was associated with male gender, poor performance status, dysphagia and early satiety. Dysphagia and early satiety were independently associated with reduced survival. There was a gender difference in survival favoring women. The effects of dysphagia, early satiety and gender were equal and nearly of similar magnitude to performance status. Symptom and gender analysis should be included in all cancer treatment and symptom control studies.

Female↗
PubMed2002

Morphine in cancer pain management: a practical guide.

Morphine is the most practical and versatile analgesic for the relief of severe pain associated with advanced cancer. Information is available in the literature about its use in routine clinical practice. Morphine induces analgesia by reducing neurotransmitter release presynaptically and hyperpolarizing dorsal horn neurons at the postsynaptic level, thus preventing rostral transmission of nociception. Morphine has a unique metabolism via glucuronidation (UGT2B7), which results in an active metabolite (morphine-6-glucuronide). The pharmacokinetics of morphine relate to its hydrophilic characteristic, volume of distribution, route of administration and clearance. Renal failure alters its pharmacokinetics more than cirrhosis. The age of the patient and multiple medications will alter morphine pharmacokinetics. Morphine can be given by several different routes: oral, rectal, subcutaneous (s.c.), intravenous (i.v.), epidural and intrathecal. Recent experience confirms benefits of topical morphine for cutaneous pain associated with benign or malignant ulcers. Guidelines for morphine administration are reviewed, and in particular those of the Harry R. Horvitz Center for Palliative Medicine are outlined.

Age Factors↗
PubMed2002

The cancer anorexia-cachexia syndrome: a survey of the Prognostic Inflammatory and Nutritional Index (PINI) in advanced disease.

Other than weight loss, most traditional methods of nutritional assessment are not acceptable in advanced cancer patients because they are inaccurate, too expensive for routine use, or too difficult for a debilitated person to complete. The prognostic inflammatory and nutritional index (PINI) is a formula devised to evaluate nutritional status and prognosis in critically ill patients. It has been suggested that the PINI score can be used to follow most pathological conditions. It has been measured in several settings and has been found to be a reliable indicator of both nutritional status and prognosis in trauma, burn, infected, and cardiac patients. In this pilot study, we evaluated the PINI in 50 consecutive patients referred to a palliative care service. Compared to a value in normal, healthy people of <1, the mean score in this sample was 102 (SD = 142, 95% CI = 62-142). The mean protein values were: alpha-1-acid glycoprotein 1409 mg/l (SD = 556, 95% CI = 1251-1567); C-reactive protein (CRP) 106 mg/l (SD = 89, 95% CI = 81-131); albumin 24 g/l (SD = 7, 95% CI = 23-26); and prealbumin 147 mg/l (SD = 73, 95% CI = 126-168). There was no significant association between the PINI and corticosteroid use, weight loss over time, age, or sex. These data indicate that the PINI is highly abnormal in our population. The CRP may be the most important value.

Aged↗
PubMed2001

Symptom control in cancer patients: the clinical pharmacology and therapeutic role of suppositories and rectal suspensions.

Rectally administered medications are essential in palliative medicine, particularly in the last days of life. They are underutilized. The pharmacology of rectally administered medications relates not only to the medication but also to the suppository base, additives, drug ionization, p K(a), absorptive surface of the rectum, and rectal health. The pharmacokinetics may differ from those of orally administered medications owing to reduced hepatic first-pass clearance. In this review the pharmacology of rectally administered palliative medications is reviewed and the use of individual drugs is outlined.

Administration, Rectal↗