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Biomedical subjects

E Bruera

Publications and source records attributed to E Bruera.

At least 91 records · Page 5Linked to original sources
PubMed1999

Nonsteroidal anti-inflammatory drugs as adjuvant analgesics in cancer patients.

The role of nonsteroidal anti-inflammatory drugs (NSAIDs) is examined in the control of cancer pain with a particular focus on their use as adjuvants to opioids in advanced cancer pain. These agents have both a peripheral effect on inflammation and a role in attenuating central pain pathways. The possibility of obtaining the benefits of NSAIDs with fewer side-effects by using COX-2-specific agents is discussed. The gastrointestinal, renal, haemostatic, cognitive and hypersensitivity side-effects of NSAIDs are reviewed and their potential impact assessed. The evidence for the efficacy of NSAIDs as single agents for cancer pain is reviewed together with the nine papers which have reported the effects of NSAIDs as adjuvants to opioids in cancer pain. All of these papers reported positive results of NSAIDs, but, in the absence of any randomized, double-blind controlled trials, where NSAIDs were used as adjuvants on a long-term basis alongside optimal opioid use, definite conclusions cannot be reached. Guidelines for the safe use of NSAIDs are suggested. Finally, suggestions for future research are made.

Analgesics↗
PubMed1999

A comparison of patient and proxy symptom assessments in advanced cancer patients.

The purpose of this study was to compare patient and proxy (physician and nurse) assessments of symptoms in advanced cancer patients. The sample consisted of 49 patients with advanced cancer admitted to an acute palliative care unit. Three independent assessments were completed for each patient on two occasions within 11 days of admission. On each occasion, symptoms were rated independently by the patient and two proxies (treating physician and nurse), using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale (VAS) for assessing pain, activity, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. Symptom ratings were compared using a repeated-measures ANOVA procedure and correlations. Average physician ratings were generally lower than average patient ratings for both occasions. Average nurse ratings agreed more closely with patient ratings, with a trend towards lower ratings on occasion 1 and higher ratings on occasion 2. There was a significant rater (person rating the effects) effect (P < 0.01) for three of the nine symptoms: physicians rated drowsiness, shortness of breath and pain significantly lower than patients. For drowsiness and shortness of breath, these differences were clinically relevant, representing a difference of more than 12 mm on a 100-mm VAS. The accuracy of assessments amongst those rating the symptoms did not improve over time. Proxy assessments of symptom intensity, particularly by physicians, were significantly lower than patient assessments for three of the nine symptoms. Further research regarding the reliability of patient and proxy assessments is needed to assess and manage symptoms in advanced cancer effectively.

Aged↗
PubMed1999

Assessing the reliability of patient, nurse, and family caregiver symptom ratings in hospitalized advanced cancer patients.

PURPOSE: The purpose of this study was to examine the reliability of symptom assessments in advanced cancer patients under various conditions, including multiple raters (patients, nurses, and family caregivers), occasions, and symptoms. PATIENTS AND METHODS: The study sample consisted of 32 advanced cancer patients admitted to a tertiary palliative care unit. Symptom assessments were completed for each patient on two separate occasions, approximately 24 hours apart. On each occasion, the patient, the primary care nurse, and a primary family caregiver independently completed an assessment using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale for assessing symptoms in palliative patients. The reliability of the assessments (r) was examined using generalizability theory. RESULTS: Three important findings emerged from this analysis. First, the analysis of individual symptom ratings provided a more meaningful representation of the symptom experience than total symptom distress ratings. Secondly, patients, nurses, and caregivers varied in their ratings across different patients, as well as in their ratings of shortness of breath, which may have been a result of individual rater variability. Finally, reliability estimates (r), based on a single rater and one occasion, were less than.70 for all symptoms, except appetite. These estimates improved substantially (r >/=.70) for all symptoms except anxiety and shortness of breath, using three raters on a single occasion or two raters across two occasions. CONCLUSION: The findings from this study reinforce the need for the development of an integrated symptom assessment approach that combines patient and proxy assessments. Further research is needed to explore individual differences among raters.

Analysis of Variance↗
PubMed1999

Role of methadone in the management of pain in cancer patients.

In most cancer patients who are treated with opioid analgesics for pain control, the type of opioid needs to be changed at least once because of the presence of side effects or the need to escalate analgesic doses to toxic levels. Methadone may be an excellent alternative in such patients due to its lack of known active metabolites, high lipid solubility, excellent absorption following oral and rectal delivery, and extremely low cost. However, it has unique problems, such as a long, unpredictable half-life and greater potency than previously assumed. At present, methadone is viewed as a second-line opioid for chronic cancer pain. Better pharmacokinetic and clinical studies are required to establish the role of methadone in this setting. Issues to be explored include a potential role in treating patients who have poorly responsive pain syndromes, such as neuropathic pain, or who develop a rapid tolerance to other opioids; the possibility of extending dosing intervals to every 12 or 24 hours; and its possible use as a first-line opioid.

Analgesics, Opioid↗
PubMed1999

Temporal distribution of deaths in cancer patients admitted to a palliative care unit.

The timing of death has received much attention, particularly in the area of sudden cardiac death. Many studies have demonstrated that sudden cardiac death and other sudden deaths follow a circadian pattern. Deaths have also been reported to vary around dates that are especially meaningful to patients and families. To test these reported observations in a cancer palliative care population, we reviewed the date and time of death of 626 consecutive patients admitted to the palliative care unit of a western Canadian hospital. All patients were adults with advanced metastatic or locally recurrent cancer. A circadian distribution in the time of deaths was observed; 225 deaths occurred between 20:00 and 06:00 (261 deaths expected) versus 401 deaths between 06:00 and 20:00 (365 deaths expected) (p = 0.0037). The distribution of deaths did not change significantly according to day of the week or month of the year. Based on patient birthday, 41 deaths occurred during the three weeks before a birthday (33.5 deaths expected) versus 26 deaths during the three weeks after a birthday (33.5 deaths expected) (p = 0.067). There appear to be fewer deaths during the evening and night; there does not appear to be a decline in deaths before the patient's birthday; and any temporal distribution of deaths in this population appears to be minimal.

Age Factors↗
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

Bus rounds for medical congresses on palliative care.

Three 4-hour bus rounds were organized as part of an international palliative care congress, to promote patient-based education both at home and in acute care hospitals. Patient cases were presented and discussed en route to and from each visit. A total of 23 medical specialists visited 16 patients (10 in three different hospitals and 6 at home). A mean of 5.3 cases were presented during each round. A total of nine journal club articles were presented, a mean of three (2-4) articles per round. A questionnaire was filled out anonymously by all 23 participants. On a scale of 1 (worst) to 5 (best) they gave the rounds an overall rating of 5 (range 4-5). These findings suggest bus rounds provide an opportunity for intensive exposure to patient-based learning, both in acute care hospitals and at home.

Canada↗
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↗