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E D Bruera

Publications and source records attributed to E D Bruera.

12 recordsLinked to original sources
PubMed2001

The impact of delirium on the circadian distribution of breakthrough analgesia in advanced cancer patients.

Most cancer patients will experience pain requiring opioid therapy during their illness. Standard opioid therapy includes fixed scheduled doses and so-called "rescue" doses for breakthrough pain. Circadian rhythms seem to influence the expression of pain and the responsiveness to analgesic medication. Delirium is a common complication in advanced cancer patients and it also may modify the expression of pain and the use of analgesic medication. We reviewed the circadian distribution of breakthrough analgesia (BTA) doses in 104 advanced cancer patients who were part of a prospective study of the occurrence of delirium. We found that the circadian distribution of BTA is significantly different from a random distribution in the case of patients with and without delirium. Patients without delirium tended to use more BTA (P < 0.001) in the morning, whereas patients with delirium tended to use more BTA in the evening and at night (P = 0.02). We conclude that delirium is associated with changes in the circadian distribution of BTA, which is possibly related to reversal of the normal circadian rhythm.

Aged↗
PubMed2000

Clinical utility, factor analysis, and further validation of the memorial delirium assessment scale in patients with advanced cancer: Assessing delirium in advanced cancer.

BACKGROUND: Delirium is a common neuropsychiatric complication in patients with advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a recently developed 10-item severity rating instrument. The purpose of the current prospective study was to further assess the clinical utility, factor structure, and validity of the MDAS in a relatively homogeneous population of patients with advanced cancer. METHODS: Study entry of 104 patients occurred on their consecutive admission to a tertiary-level, acute palliative care unit in a university-affiliated teaching hospital. Patients underwent regular cognitive screening using the Mini-Mental State Examination, and serial monitoring of delirium using standardized semistructured interviews and MDAS ratings, up to the study endpoints of either patient discharge or death. RESULTS: Seventy-one patients met Diagnostic and Statistical Manual (of Mental Disorders)-IV criteria for a first episode of delirium. In 15 of 71 (21%) patients with a first episode of delirium, the first MDAS ratings were prorated because of dyspnea, fatigue, or profound delirium. In the remaining 56 patients (79%), the first MDAS ratings were rated fully and therefore evaluable. Correlations among the scale items ranged from moderate to low (correlation coefficient [r] = 0.68-0.02). Analysis of the pattern of factor loadings identified two primary correlated factors: global cognitive (Factor I) and neurobehavioral (Factor II) (r = 0.33). Cronbach alpha coefficients for Factors I and II were 0.8 and 0.66, respectively, indicating a relatively high level of correlation for items within each. The Cronbach alpha coefficient for all 10 items was 0.78, suggesting a general underlying factor. In a larger sample of complete MDAS ratings (n = 330) a cutoff total MDAS score of 7 of 30 yielded the highest sensitivity (98%) and specificity (96%) for delirium diagnosis. The MDAS was correlated moderately with the Mini-Mental State Examination (r = 0.55). CONCLUSIONS: The authors concluded that the MDAS structure is representative of the many features of delirium, broadly grouped as global cognitive and neurobehavioral dimensions. Prorating item scores is necessary in approximately 20% of advanced cancer patients with delirium. This poses potential limitations on the applicability of the MDAS in research. Conversely, the ability to prorate item scores confers a clinical advantage to the instrument when assessing delirium in a patient population with advanced cancer.

Aged↗
PubMed2000

Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study.

CONTEXT: Delirium impedes communication and contributes to symptom distress in patients with advanced cancer. There are few prospective data on the reversal of delirium in this population. OBJECTIVES: To evaluate the occurrence, precipitating factors, and reversibility of delirium in patients with advanced cancer. DESIGN: Prospective serial assessment in a consecutive cohort of 113 patients with advanced cancer. Precipitating factors were examined using standardized criteria; 104 patients met eligibility criteria. SETTING: Acute palliative care unit in a university-affiliated teaching hospital. MAIN OUTCOME MEASURES: Delirium occurrence and reversal rates, duration, and patient survival. Strengths of association of various precipitating factors with reversal were expressed as hazard ratios (HRs) in univariate and multivariate analyses. RESULTS: On admission, delirium was diagnosed in 44 patients (42%), and of the remaining 60, delirium developed in 27 (45%). Reversal of delirium occurred in 46 (49%) of 94 episodes in 71 patients. Terminal delirium occurred in 46 (88%) of the 52 deaths. In univariate analysis, psychoactive medications, predominantly opioids (HR, 8.85; 95% confidence interval [CI], 2.13-36.74), and dehydration (HR, 2.35; 95% CI, 1.20-4.62) were associated with reversibility. Hypoxic encephalopathy (HR, 0.39; 95% CI, 0.19-0.80) and metabolic factors (HR, 0.44; 95% CI, 0.21-0.91) were associated with nonreversibility. In mulitivariate analysis, psychoactive medications (HR, 6.65; 95% CI, 1.49-29.62), hypoxic encephalopathy (HR, 0.32; 95% CI, 0.15-0.70), and nonrespiratory infection (HR, 0.23; 95% CI, 0.08-0.64) had independent associations. Patients with delirium had poorer survival rates than controls (P<.001). CONCLUSIONS: Delirium is a frequent, multifactorial complication in advanced cancer. Despite its terminal presentation in most patients, delirium is reversible in approximately 50% of episodes. Delirium precipitated by opioids and other psychoactive medications and dehydration is frequently reversible with change of opioid or dose reduction, discontinuation of unnecessary psychoactive medication, or hydration, respectively.

Aged↗
PubMed2000

Opioid type and other clinical predictors of laxative dose in advanced cancer patients: a retrospective study.

BACKGROUND: Constipation is a frequent and underdiagnosed complication in patients with advanced cancer. Constipation in this population is multifactorial, but the use of opioids is one of the main causes. The purpose of this retrospective study was to establish the association between opioid type and laxative dose, as well as the contribution of other clinical factors in advanced cancer patients admitted to a palliative care unit. METHODS: The records of consecutive patients admitted to the Acute Palliative Care Unit at the Grey Nuns Hospital between December 1995 and January 1997 were reviewed. Criteria of eligibility were the presence of cancer pain treated by opioids (oral and subcutaneous morphine and hydromorphone, oral methadone), oral laxative treatment capable of achieving at least one bowel movement every 3 days, and the absence of bowel obstruction or colostomy. During period(s) of stable analgesic doses, the charts were reviewed for demographic and clinical characteristics, average number of bowel movements, daily laxative doses, doses and type of opioid, laxative/opioid dose ratio (LOR) (calculated by dividing the total laxative dose by the total opioid dose), functional and cognitive status, food intake, and level of calcium, albumin, and potassium. RESULTS: Forty-nine evaluable patients were identified. The LOR in patients receiving oral opioids was 0.15 +/- 0.19 vs. 0.18 +/- 0.17 in patients on parenteral opioids (p > 0.2). The LOR in patients receiving methadone was 0.025 +/- 0.027 as compared to 0.24 +/- 0.23 in patients receiving morphine and 0.17 +/- 0.13 in patients on hydromorphone (p < 0.0001). We found a strong association between LOR and abdominal involvement (p < 0.0006), opioid type (p < 0.0001), age (p < 0.0001), and female gender (p < 0.034). There were no significant correlation between LOR and functional status, cognitive status, food intake, and level of calcium or potassium. CONCLUSION: We conclude that laxative dose needs to be titrated on an individualized basis. The LOR is lower in patients receiving methadone and in those of male gender, younger age, and absence of abdominal involvement.

Journal Article↗
PubMed2000

Internet usage among women with breast cancer: an exploratory study.

An increasing number of breast cancer patients are accessing the Internet for medical information. A survey was administered to breast cancer patients and their families attending follow-up outpatient clinics in a comprehensive cancer care center to explore their frequency of Internet use, their motivation for online activity, the type of information they sought, and the perceived impact of the information they found on the Internet on their medical care. The survey was conducted over a 4-month period. A total of 107 surveys were returned. Seventy-nine of these (74%) were from patients while 28 (26%) were from family members and friends. Thirty-four of the patient responses (43%) indicated that the patient had used the Internet to look for cancer-related information. Patients who had used the Internet to access cancer-related information were significantly younger (P = 0.007), better educated (P = 0.027), and less satisfied with the amount of treatment-related information given by caregivers than those patients who had not used the Internet to access cancer-related information (P = 0.032). The majority of patient Internet users desired more information on their cancer and its treatment (91%), looked up information that was presented to them by their clinicians (66%), researched other treatment options (63%), and obtained more information on "alternative treatments" (63%). Patient Internet users generally found the cancer-related information on the Internet to be useful, and the majority discussed Internet-derived information with their health care providers and perceived that clinicians listened to such information. However, 53% were undecided about the trustworthiness of the medical information obtained via the Internet. Internet nonusers commonly lacked Internet access (53%) or were unfamiliar with the Internet (33%), but few (13%) distrusted Internet-derived information. This exploratory study underscores the need for more research in this area, specifically with the aims of identifying and verifying factors that lead patients to use the Internet and the impact of their online activities on their medical care.

Adult↗
PubMed1998

Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study.

BACKGROUND: Current equianalgesic reference tables, based largely on single dose studies, give dose ratios of 1:1 to 4:1 for oral morphine to oral methadone, which possibly are inaccurate in patients with cancer pain who are exposed to multiple doses of these opioids. The purpose of this study was to determine the equianalgesic dose ratio between morphine and methadone in patients with cancer pain and to establish whether the dose ratio changes as a function of previous opioid dose. METHODS: A retrospective analysis of consecutive rotations involving morphine and methadone using standard selection criteria identified a total of 20 evaluable rotations (14 from morphine to methadone and 6 from methadone to morphine). Opioid doses and pain intensity levels pre- and postrotation were analyzed. RESULTS: Median dose ratios (lower-upper quartiles) for morphine to methadone and methadone to morphine rotations were 11.36 (range, 5.98-16.27) and 8.25 (range, 4.37-11.3), respectively (P = 0.23). Combining all 20 rotations, a unified median dose ratio of 11.2 (range, 5.06-13.24) was calculated. There was no significant difference in pain intensity levels pre- and postrotation as recorded on a visual analogue scale. Univariate correlational analysis of dose ratio and the level of daily morphine dose prior to rotation revealed a Spearman correlation coefficient of 0.86 (P = 0.0001). In patients receiving >1165 mg per day prior to methadone rotation, a median dose ratio of 16.84 (range, 12.25-87.95) was observed, which was approximately 3 times higher compared with a median dose ratio of 5.42 (range, 2.95-9.09) (P = 0.007) for the 50% of patients receiving lower morphine doses. CONCLUSIONS: The results highlight the general underestimation of methadone potency and the consequent risk of potential life-threatening toxicity. The strongly positive correlation between dose ratio and previous morphine dose suggests the need for a highly individualized and cautious approach when rotating from morphine to methadone in patients with cancer pain.

Administration, Oral↗
PubMed1994

Comparison of the efficacy, safety, and pharmacokinetics of controlled release and immediate release metoclopramide for the management of chronic nausea in patients with advanced cancer.

BACKGROUND: The short elimination half-life of metoclopramide necessitates frequent administration for optimal relief of nausea. This study compares a newly developed controlled release preparation of metoclopramide (CRM) and immediate release metoclopramide (IRM) with respect to efficacy, safety, and pharmacokinetics in patients with chronic nausea associated with advanced cancer. METHODS: Thirty-four patients with advanced cancer with nausea lasting more than 1 month and with no evidence of involvement of the gastrointestinal tract, peptic ulcer or gastritis, brain metastases, or metabolic abnormalities were randomized, in a double-blind cross-over study, to receive 40 mg of CRM every 12 hours or 20 mg of IRM every 6 hours for 3 days. Nausea, food intake, and side effects were assessed four times daily. On Day 3, sequential venous samples were taken (12 patients) to determine plasma metoclopramide concentrations. RESULTS: In 29 evaluable patients, the intensity of nausea on Day 3, measured by a 0-100-mm visual analogue scale and 0-3 categoric scale was 15 +/- 17 and 0.6 +/- 0.6 after IRM, versus 8 +/- 9 (P = 0.033) and 0.4 +/- 0.5 (P = 0.055) after CRM, respectively. Visual analogue scale nausea scores recorded by time of day and by day for the 3 treatment days were significantly lower for patients who received CRM compared with those who received IRM (P = 0.047 and P = 0.043, respectively), but categoric nausea scores were not significantly different between treatments by time of day and by day across the 3 treatment days. No differences were observed in caloric intake or side effects between treatments. In a pharmacokinetic analysis, the CRM/IRM ratio for area under the curve0-12 (microgram x hours x L-1), Cmax (microgram/L), and Tmax (hours) was 100%, 98%, and 2.3 fold, respectively. CONCLUSION: Controlled release metoclopramide is safe and effective in managing chronic nausea in patients with advanced cancer. Future studies should focus on characterizing this syndrome more clearly and on determining the optimal dose of metoclopramide and the effects of drug combinations that have proven to be useful in managing chemotherapy-induced emesis (i.e., metoclopramide plus corticosteroids).

Chronic Disease↗
PubMed1983

Improved control of chemotherapy-induced emesis by the addition of dexamethasone to metoclopramide in patients resistant to metoclopramide.

One hundred and two patients with advanced solid tumors receiving chemotherapy were treated with metoclopramide (MCP; 100 mg) to prevent emesis. Twenty-six of 102 patients who had more than five episodes of vomiting were considered MCP-resistant and were randomized to receive MCP (100 mg) plus placebo versus MCP plus dexamethasone (DM; 48 mg) iv in a double-blind, crossover trial. The median number of vomiting episodes was 18 after MCP plus placebo and five after MCP plus DM (P less than 0.001). The median duration of vomiting episodes was 40 hours after MCP plus placebo and 10 hours after MCP plus DM. Immediate toxicity of the antiemetics was not enhanced by the addition of DM to MCP.

Adult↗