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Biomedical subjects

E Bruera

Publications and source records attributed to E Bruera.

At least 19 recordsLinked to original sources
PubMed1998

Age, pain intensity, and opioid dose in patients with advanced cancer.

BACKGROUND: Elderly patients are more likely to be affected by the acute and chronic toxicities of opioids, but an association between age and long term opioid consumption has not been established clearly in patients with advanced cancer. METHODS: The computerized records of 197 cancer patients admitted to a palliative care unit in Edmonton, Alberta, Canada were examined. The authors examined: demographics (age, gender, and location of primary tumor), pain characteristics (presence of neuropathic pain and incidental pain), mean daily pain intensity (MDPI), and daily opioid consumption measured as (parenteral) morphine equivalent daily dose (MEDD). MDPI and MEDD were assessed on Days 2 and 7 after admission, on the day of maximum opioid consumption, and on the day of maximum pain intensity during admission. Average values for MDPI and MEDD were calculated between Days 2 and 7. RESULTS: When age was treated as a categoric variable (< 65 years, 65-74 years, and 75+ years), statistically significant differences in MEDD were observed for age for all estimates except those for Day 7, with older patients requiring a lower equianalgesic dose. No major differences were observed for pain intensity and for the presence of incidental or neuropathic pain across the different age groups. In the multivariate analysis, the reduction in MEDD ranged between 27-71 mg when patients age > or = 75 years were compared with younger adults. A MEDD increase that ranged between 82-137 mg was associated with the presence of neuropathic pain. CONCLUSIONS: The current study suggests that elderly cancer patients may experience a similar level of pain intensity but require a lower amount of opioid analgesia than younger adults. However, because elderly patients are more likely to be affected by the acute and chronic toxicities of opioids, opioids should be initially administered at a lower dose and titrated cautiously in these patients.

Adult↗
PubMed1998

Management of specific symptom complexes in patients receiving palliative care.

During the past 10 years there have been major changes in the management of the most common symptoms of terminal cancer. Opioid agonists remain the mainstay in the management of cancer pain. Slow-release preparations are currently available for several of these agents. The increased use of opioids has led to the recognition of opioid-induced neurotoxic effects and to the development of effective adjuvant drugs and other strategies to counteract these side effects. A number of drugs are available for the management of symptoms of cachexia, including corticosteroids and progestational drugs. Prokinetic drugs, either alone or in combination with other agents such as corticosteroids, are highly effective in the treatment of chronic nausea. For patients with asthenia, it should first be determined whether there are any reversible causes; if not, corticosteroids and psychostimulants may diminish the symptoms. Haloperidol, other neuroleptics and benzodiazepines may be required to manage hyperactive delirium. Oxygen and opioids are effective in treating dyspnea, whereas there is limited evidence that benzodiazepines provide any relief of this symptom. More research on the assessment and management of these devastating clinical symptoms of cancer is badly needed.

Asthenia↗
PubMed1998

Pharmacological treatment of cachexia: any progress?

In view of the renewed interest in pharmacological treatment of anorexia-cachexia in cancer patients over the past 3 years, both the established drugs used in its treatment and the emerging new drugs still being tested for it are reviewed. Results of trials that have already been evaluated are reported, and possible areas for further research are indicated.

Adrenal Cortex Hormones↗
PubMed1998

Constipation in advanced cancer patients.

Constipation is a frequent, distressing, and underestimated complication in patients with advanced cancer. It may develop from general disturbances that may or may not be cancer related, but the use of opioids is one of the main causes in this population. Opioids affect the intestine by reducing motility and secretions and by increasing fluid absorption and blood flow. Untreated constipation may lead to several complications. Effective management of constipation starts with a careful assessment of the patient, including the history of the frequency and difficulty of defaecation, symptoms caused by constipation, and physical and rectal examinations. When the diagnosis of constipation is unclear, an abdominal X-ray may be required. The treatment of constipation includes general interventions, such as the availability of comfort and privacy or the elimination of medical factors that may contribute to constipation, and therapeutic interventions including oral or rectal laxatives and the use of prokinetic drugs and naloxone. The purpose of this paper is to review the pathophysiology and causes of constipation and the effects of opioids on the gastrointestinal tract, and to propose an approach for its assessment and management. Randomized clinical trials between different laxatives and/or prokinetic agents in cancer patients are needed, and future studies should focus on the validation of different clinical assessment tools for constipation.

Constipation↗
PubMed1998

Palliative management of brain metastases.

The development of brain metastases in patients with advanced cancer is associated with increased morbidity and diminished longevity. Palliative treatment modalities focus predominantly on improving quality of life. Well-established beneficial treatments include the use of corticosteroids, radiotherapy, and surgery. Management issues that require further exploration and clarification include the dosages of glucocorticoids, the prophylactic use of anticonvulsants and the indications for radiosurgery.

Adrenal Cortex Hormones↗
PubMed1998

Proctoclysis for hydration of terminally ill cancer patients.

In a prospective, open study, 78 patients with terminal cancer received proctoclysis (rectal hydration) in four different centers. In all cases, a #22 French nasogastric catheter was inserted approximately 40 cm into the rectum and an infusion of normal saline (2 cases) or tap water (76 cases) was administered at a rate of 250 +/- 63 cc/hr. Hydration was maintained for 15 +/- 8 days. The main reason for discontinuation of hydration was death (60 cases). The mean visual analogue score for discomfort after infusion (0 = no discomfort, 100 = worst possible discomfort) was 19 +/- 14. The costs of proctoclysis was estimated at Can$0.08 compared with Can$4.56 per day for hypodermoclysis, and Can$2.78 per day for intravenous hydration. Our results suggest that proctoclysis is a safe, effective, and low-cost technique for the delivery of hydration in terminally ill cancer patients.

Administration, Rectal↗
PubMed1998

The Internet as a resource for palliative care and hospice: a review and proposals.

The last 3 years have witnessed an enormous growth and utilization of the Internet and its graphical subdivision, the World Wide Web (WWW). Its medical applications offer numerous advantages and strengths, including ease of publication and access to large volumes of information. This paper explores the potential applications of the Internet and the WWW for palliative care and hospice. It will describe the reasons for the immense interest in this medium and discuss the various strengths and weakness of the Internet and the World Wide Web as a Palliative Care resource. Foremost among these weaknesses is the lack of editorial control and the peer review process, allowing anecdotal and unbalanced information to be published. To provide the growing number of health-care professionals and patients who utilize this medium with balanced, evidence-based information, publishing by various palliative care and hospice organizations needs to be encouraged and palliative care electronic journal publishing needs to be accelerated.

Computer Communication Networks↗
PubMed1998

Baclofen, a treatment for chronic hiccup.

The efficacy of baclofen in the treatment of chronic hiccup is demonstrated in two cases. These cases highlight the present state of knowledge related to hiccup. This discussion focuses on the definition and classification of hiccup, etiologies, postulated theories to explain its function, the few studies performed to date, and non-pharmacologic and pharmacologic treatment. Baclofen appears to be the agent most efficacious in the treatment of chronic hiccup. Its commonest side effect is sedation; insomnia, dizziness, weakness, ataxia, and confusion also can occur. Following regular use, abrupt discontinuation can lead to withdrawal symptoms, such as seizure, and gradual discontinuation is recommended.

Aged↗
PubMed1998

Equianalgesic dose/ratio between methadone and other opioid agonists in cancer pain: comparison of two clinical experiences.

BACKGROUND: Oral methadone is considered to be a valid opioid analgesic alternative to morphine and hydromorphone in treating cancer pain. However, the use of methadone could be complicated by the limited knowledge of the equianalgesic dose/ratio with the other analgesic opioids when switching in tolerant patients. PATIENTS AND METHODS: In two Palliative Care Units, data collected regarding 88 advanced cancer patients with pain switched from different opioids to oral methadone were reviewed and compared with the aim of determining the equianalgesic dose ratio in relation to the dose of opioid previously administered. RESULTS: The results of this retrospective study suggest that: (1) methadone is much more potent than previously described in literature, (2) the dose ratio between hydromorphone and methadone is higher than as suggested by equianalgesic tables, and (3) the ratio correlates with total opioid dose administered before switching. CONCLUSIONS: The fact that methadone ratio is different according to the opioid dose used previously should be taken into careful consideration by the clinician in order to avoid severe toxicity or death during switchover. Prospective studies should be carried out in order to better define our findings.

Administration, Oral↗
PubMed1998

Results of a phase III, double-blind, placebo-controlled trial of megestrol acetate modulation of P-glycoprotein-mediated drug resistance in the first-line management of small-cell lung carcinoma.

The objective of this study was to determine if the addition of megestrol acetate (MA), a modulator of P-glycoprotein-mediated drug resistance, to first-line cytotoxic therapy in patients with limited and advanced stage small-cell lung cancer (SCLC) would improve median time to disease progression and median overall survival. Secondary outcomes evaluated were response rates and patient symptom profile. Between 1992 and 1995, 130 eligible patients were randomized in a double-blind fashion to receive standard first-line therapy consisting of alternating courses of cyclophosphamide/doxorubicin/vincristine and etoposide/cisplatin (and thoracic radiotherapy for limited stage patients), along with either placebo or MA 160 mg t.i.d. for 8 days commencing 3 days before initiation of each cycle of chemotherapy. Treatment was continued for a maximum of six cycles. A total of 130 eligible patients were randomized, 65 to each arm. Fifty-two per cent of patients had limited disease and 48% had advanced disease. The median time to disease progression in limited stage disease was 46 weeks in the placebo arm and 43 weeks in the MA arm (P = 0.71) and in advanced stage disease was 28 weeks in the placebo arm and 27 weeks in the MA arm (P = 0.92). The median overall survival in limited stage disease was 75 weeks in the placebo arm and 75 weeks in the MA arm (P = 0.56) and in advanced stage disease was 41 weeks in the placebo arm and 39 weeks in the MA arm (P = 0.96). There was no consistent statistical difference in response rates or patient symptom profiles between the two treatment arms. The addition of MA, in the dose and schedule used, to standard first-line cytotoxic therapy in SCLC did not result in a significant improvement in response rates, symptom profile, median time to disease progression or overall survival.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed1998

Access to palliative medicine training for Canadian family medicine residents.

The authors conducted a nine-item mail questionnaire of the 16 Canadian family medicine teaching programme directors to determine the accessibility and operation of palliative care education for their respective family medicine residents. All 16 faculties of medicine responded (100%). The survey revealed that while all universities offer elective time in palliative care only five out of 16 (31%) have a mandatory rotation. The median durations of the mandatory and elective rotations are limited to two and three-and-a-half weeks, respectively. The majority of the universities offer formal lectures in palliative care (12/16, 75%) and educational reading material (13/16, 81%), with the main format in 14/16 (87%) of the sites being case-based learning. The two most common sites for teaching to occur for the residents are the community/outpatient environment and an acute palliative care unit. Fifty-six per cent (9/16) of the universities have designated faculty positions for palliative medicine with a median number of two positions per site. Only one centre offers a specific palliative medicine examination during the rotation. Feedback from the residents regarding their respective palliative medicine programmes were positive overall. Findings from our survey indicate an ongoing need for improved education in palliative medicine at the postgraduate level.

Canada↗
PubMed1998

A review of the drug treatment of cachexia associated with cancer.

In the past 20 years, cachexia in cancer patients has attracted increasing interest from both clinicians and basic researchers. It is now clear that the cachexia is secondary to major metabolic abnormalities due to tumour by-products and cytokine release. These metabolic abnormalities produce numerous symptoms such as cachexia, anorexia and asthenia. There are now effective drugs such as corticosteroids and progestational drugs that have been shown to improve appetite, food intake and sensation of well-being, and which elicit bodyweight gain. While hydrazine (hydrazine sulfate) has received much attention, unfortunately it has been shown to be ineffective in improving the symptoms of the patient with cancer cachexia. A new group of drugs, such as thalidomide and melatonin because of their effects on tumour necrosis factor-alpha, and beta 2-adrenoceptor agonists because of their effects on muscle metabolism, and other agents, is presently reaching the clinical trial stage. There is now the possibility of addressing this fascinating syndrome at a different level and an opportunity for combined therapy to try to improve the quality of life of these patients.

Cachexia↗
PubMed1998

Assessment and management of medically ill patients who refuse life-prolonging treatments: two case reports and proposed guidelines. Capital Health Authority Regional Palliative Care Program.

Patients who have chosen to have treatment withdrawn because of debilitating conditions pose a special problem for palliative care. We report on two such patients: patient 1 refused amputation of a gangrenous leg and patient 2 refused food and hydration after a series of strokes. The management of these patients through the dying process is discussed and guidelines are suggested. The criteria for competency include both a general cognitive and psychiatric assessment as well as a specific evaluation of the patient's ability to make the treatment withdrawal decision. Treatable symptoms which impair the patient's quality of life and have an impact on the decision should be corrected. If a proxy decides to withdraw therapy in an incompetent patient, this decision should accord with the patient's known wishes and values as far as possible. The beneficence of the decision may be assessed according to the disease process, degree of suffering, and risks of accepting treatment. The complexity of these cases calls for a multidisciplinary approach, and the palliative care team should work in collaboration with the primary care treatment team.

Aged↗
PubMed1998

Methods of hydration in palliative care patients.

A strong and often polarized debate has taken place during recent years concerning the consequences of dehydration in the terminally ill patient. When a patient has a severely restricted oral intake or is found to be dehydrated, the decision to administer fluids should be individualized and made on the basis of a careful assessment that considers problems related to dehydration, potential risks and benefits of fluid replacement, and patients' and families' wishes. This review discusses the assessment of hydration status in the terminal cancer patient and the options for fluid administration in the cases where evaluation of the patients' condition has led to this indication. These include different modes of hypodermoclysis, intravenous hydration, use of the nasogastric route, and proctoclysis. Arguments for and against rehydration have been previously addressed by other authors and fall outside the scope of this review.

Dehydration↗