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Biomedical subjects

E Bruera

Publications and source records attributed to E Bruera.

At least 127 records · Page 7Linked to original sources
PubMed1998

Effectiveness of megestrol acetate in patients with advanced cancer: a randomized, double-blind, crossover study.

PURPOSE: To evaluate the effect of megestrol acetate at a lower dose than previously investigated on the symptoms of cachexia in patients with advanced cancer. METHODS: A total of 84 patients with advanced, solid tumours not responsive to hormone therapy were enrolled in this double-blind, crossover study. During phase 1, patients were randomly assigned to receive megestrol acetate (160 mg 3 times daily) for 10 days or placebo. During phase 2, after a 2-day washout period, patients received the alternate treatment for 10 days. Patients underwent daily assessments of activity, nausea, appetite and well-being by means of a visual analogue scale (VAS). In addition, nutritional status (weight, tricep skinfold measure, arm muscle circumference), energy intake, fatigue (Piper Fatigue Scale) and quality of life (Functional Living Index-Cancer [FLIC]) were assessed. RESULTS: Among the 53 evaluable patients megestrol acetate resulted in a significant improvement in appetite (p = 0.005), activity (p = 0.007) and well-being (p = 0.03). There was no significant change in the intensity of nausea, nutritional parameters, energy intake or FLIC scores. There was a significant improvement in 2 of the 3 factors measured by the Piper Fatigue Scale and in the overall fatigue score. Upon completion of the study, while still blind to the treatment condition, 30 patients indicated that they felt better overall after megestrol, 15 said they felt better after placebo, and 10 indicated no preference (p = 0.001). CONCLUSION: Treatment with megestrol acetate results in rapid and significant improvement of symptoms in terminally ill patients at lower doses than previously reported. The effects are not secondary to nutritional changes. The FLIC quality-of-life questionnaire was unable to detect these changes.

Adult↗
PubMed1998

The use of complementary medications by cancer patients attending an outpatient pain and symptom clinic.

Complementary medications appear to be gaining popularity among cancer patients. When we surveyed 143 advanced cancer patients attending an outpatient pain and symptom clinic at a regional cancer centre as to their use of complementary medications and nutritional supplements, we found 37% (53/143) to be making use of complementary medications. Users tended to be younger (mean age 53.3 years) and have a preference for purchase from health stores, with 61% of complementary medications being bought there. Health store staff were the primary recommenders for both men and women and especially for those over 60 years of age. Of the 197 complementary medications purchased, 78 (39.6%) were herbs, 67 (32.5%) were vitamins, 13 (6.6%) were minerals, 21 (10.7%) were other medications including shark cartilage, and 21 (10.7%) could not be identified. Both anticancer effect and the promotion of well-being were prominent among the stated reasons for using these medications.

Alberta↗
PubMed1998

Integration of palliative care with alternative medicine in patients who have refused curative cancer therapy: a report of two cases.

This article describes two young, potentially curable patients who chose a course of treatment that ultimately resulted in death. Their choice was in part influenced by the prospect of the disfiguring surgery that would have been required for cure. In the first patient this would have meant massive head and neck surgery, in the second, a radical hysterectomy that would have resulted in surgical menopause. The availability of practitioners who promised an easier cure was also a factor in swaying the first patient away from truly curative therapy. Denial also played a role in both of these patients' decisions. Part of their denial may have been exacerbated by the fact that both of their cancers have as risk factors behaviors that the patients may have considered inconsistent with their value system. In the first type of cancer, alcohol and chewing tobacco are major risk factors (11), neither of which would have been acceptable to the patient's family. In the second type, multiple sexual partners are a major risk for cervical cancer (12), a behavior which is inconsistent with the teachings of the patient's fundamentalist Christian beliefs. The approach that we have described--expressions of respect for the patient's belief system combined with the nonconfrontational offering of treatments with immediate symptomatic benefit--resulted in the development of an effective working relationship between patient, family, and palliative care team.

Adult↗
PubMed1997

Bus rounds for palliative care education in the community.

Increasingly, patients with cancer are dying at home and in continuing care facilities. The purpose of bus rounds is to provide continuing education to physicians and nurse palliative care consultants, to familiarize family physicians with the delivery of care in these settings and to educate family medicine and specialty residents as well as medical students. A total of 18 4-hour bus rounds took place during 1996. A mean of 13 (range 9 to 17) participants attended, to discuss a mean of 3.5 (range 2 to 4) patients and 4.5 (range 3 to 8) journal articles. A questionnaire was filled out anonymously by 18 first-time medical and 24 first-time nursing participants. On a scale from 1 (worst) to 5 (best), they gave the rounds an overall rating of 5 (range 4 to 5). The mean cost per round was $245.40. The authors conclude that bus rounds provide an opportunity for intensive exposure to community-based learning for physicians, nurses and students and are highly satisfactory from the participants' perspective.

Alberta↗
PubMed1997

The frequency and clinical course of cognitive impairment in patients with terminal cancer.

BACKGROUND: Cognitive disorders are among the most frequent psychiatric complications of advanced cancer. This study reviews the frequency and clinical course of cognitive failure in patients with advanced cancer admitted to a palliative care unit. METHODS: In this retrospective study, all 348 patients admitted to the Edmonton General Palliative Care Unit over a period of 26 months were reviewed. The Mini-Mental State Examination (MMSE) was used as a screening tool to assess cognitive functioning and was performed on all patients at the time of admission and once to twice weekly thereafter. In all cases, when cognitive failure was diagnosed, a standardized management protocol was followed. RESULTS: Three hundred and twenty-one patients (92.2%) were evaluable. A total of 1441 MMSEs were performed. Each patient underwent an average of 4.7 +/- 4.26 MMSEs and every patient underwent an MMSE every 4.9 (+/- 3.3) days (median, 3.6 days). The mean age (standard deviation [SD]) of the study group was 64.2 (+/- 12) and the mean +/- SD (median) length of stay was 27 +/- 22 (20.5) days. Two hundred and thirty-one patients (71%) died on the unit. One hundred and forty-two patients (44%) had abnormal MMSE scores (MMSE < 0.8) on admission, whereas 176 patients (55%) had abnormal MMSE scores at the time of death or discharge. Of the 231 patients who died on the unit, 157 (68%) had abnormal MMSE scores prior to death. There was no significant difference in the first MMSE between patients who died and those who were discharged (P = 0.16). Of the 240 patients who underwent 2 or more MMSEs, 99 (41%) had normal initial and final MMSEs, 54 (23%) had normal initial MMSE scores but abnormal final scores, and 62 (26%) had both initial and final abnormal scores. Of the 87 surviving patients with an MMSE score of < 0.8 on admission, 25 (29%) had initial abnormal and final normal scores, indicating an improvement. Twelve of these 25 patients (48%) with abnormal initial scores but normal final scores were discharged versus 52 of 99 patients (53%) with normal initial and final MMSE scores (P > 0.2). Of 124 patients with normal final MMSE scores, 64 (52%) were discharged versus 16 of 116 patients (14%) who had abnormal MMSE final scores (P < 0.0001). CONCLUSIONS: These data suggest that cognitive screening should take place in patients with advanced cancer because cognitive failure is highly prevalent in this population, is reversible in a significant proportion of patients, and the presence of sustained cognitive impairment is a poor prognosticator for discharge. However, these results need to be confirmed in prospective studies.

Cognition Disorders↗
PubMed1997

When to treat dehydration in a terminally ill patient?

The need to treat dehydration in terminally ill patients has become a very controversial topic. Numerous reports in the literature illustrate opposing view-points from both clinical and ethical perspectives. Arguments for the maintenance of hydration in terminally ill patients have tended to come from "the traditional medical model". Many health care professionals looking after terminally ill patients have reacted to the generalized use of intravenous fluids in dying patients and the perceived negative effects of this management. Our palliative care group has argued that the viewpoint that dehydration in dying patients is not a cause of symptom distress overlooks commonly reported problems, such as agitated delirium, that can be prevented or reversed by the management of dehydration. This review presents a summary of the traditional arguments, a different perspective on the controversy, biochemical parameters reported in terminally ill cancer patients, recent dehydration research, and the use of hypodermoclysis and rectal hydration. We conclude that the data reported to date are insufficient to allow a final conclusion on the benefit or harm of dehydration in terminally ill patients. Nevertheless, it is worth considering that while some dying patients may not suffer any ill effects from dehydration, there may be others who do manifest symptoms, such as confusion or opioid toxicity, that might be alleviated or prevented by parenteral hydration.

Dehydration↗
PubMed1997

Matching the clinical function and symptom status with the expectations of patients with advanced cancer, their families, and health care workers.

Continuous accurate assessment is mandatory for palliative care of good quality. One of the major objectives in palliation is to meet the expectations of patient, family members and care givers. While a number of valid tools for assessing symptoms or function are available, there are unfortunately no recognized instruments for assessing expectations. The mismatch of expectations and the actual situation is a major source of distress and conflict. The present paper describes a simple way of visualizing this distress and conflict graphically. In our experience, this method is helpful in raising awareness of and enabling analysis of distress and conflict in patients, family members, and health care workers. It is also useful in the education of students and members of the palliative care team. It is illustrated with reference to four clinical situations.

Adaptation, Psychological↗
PubMed1997

Acute neuropsychiatric findings in a patient receiving fentanyl for cancer pain.

A 62-year-old man receiving subcutaneous fentanyl for the management of cancer pain developed generalized central excitation after an overdose of 5000 micrograms of fentanyl. The patient developed acute confusion, restlessness, generalized myoclonus, visual hallucinations, and hyperalgesia and tremors upon tactile stimulation of the arms or legs. These symptoms rapidly disappeared after the administration of 0.2 mg of naloxone. Within an hour the symptoms reappeared and once again, responded immediately after a second injection of 0.2 mg of naloxone. Our findings suggest that fentanyl overdose can occasionally present with general central irritability that responds to naloxone.

Adenocarcinoma↗
PubMed1997

An update on the clinical use of methadone for cancer pain.

Methadone is a synthetic opioid agonist considered a second choice drug in the management of cancer pain. Methadone has a number of unique characteristics including excellent oral and rectal absorption, no known active metabolites, high potency, low cost, and longer administration intervals, as well as an incomplete cross-tolerance with respect to other mu-opioid receptor agonist drugs. For these reasons, methadone has the potential of playing a major role in the treatment of cancer pain. However, its use is limited by the remarkably long and unpredictable half-life, large inter-individual variations in pharmacokinetics, the potential for delayed toxicity, and above all by the limited knowledge of correct administration intervals and the equianalgesic ratio with other opioids when administered chronically. Recent findings suggest that standard equianalgesic tables are unreliable for methadone titration in patients tolerant to high doses of opioid agonists and that switchovers should take place slowly and should be personalized. Future research has to better define the variation in both bioavailability and elimination of methadone in different patient populations, the interaction between methadone and the most commonly used drugs in cancer patients, the type and activity of potential methadone metabolites, and the equianalgesic doses between methadone and the most commonly used opioids.

Administration, Oral↗
PubMed1997

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

Morphine (M) and hydromorphone (HM) are commonly used opioid analgesics for cancer pain. Opioid rotation is often necessary in the event of toxicity and/or inadequate analgesia. Equianalgesic reference tables based on single dose comparisons are possibly inadequate for patients on chronic treatment and developing tolerance. This retrospective study of opioid rotation involving M and HM sought to determine the equianalgesic dose ratio for 91 rotations in 74 consecutively evaluable cancer pain patients. Only rotations involving subcutaneous (s.c.-s.c.) and oral (p.o.-p.o.) routes were evaluated. There were 44 rotations from M-HM (34: s.c.-s.c., 10: p.o.-p.o.) and 47 rotations from HM-M (35: s.c.-s.c., 12: p.o.-p.o.). Expressing all ratios as M/HM, the median dose ratios (lower-upper quartiles) for s.c. and p.o. rotations were 4.92 (4.1-5.9) vs. 5.76 (4.9-5.8) for M-HM (P = 0.28, NS) and 4.0 (3.1-4.8) vs. 3.45 (2.8-4.2) for HM-M (P = 0.4, NS), respectively. Pain intensity, as measured on a visual analogue scale (VASP), showed no significant difference between mean values pre- and post-rotation. A unified overall median dose ratio of 4.29 (3.3-5.3, lower-upper quartiles) was calculated by expressing all of the HM-M dose ratios as M/HM and combining them with the dose ratios for all of the M-HM rotations. This suggests a potency ratio of approximately 4.3:1 between M and HM. When expressed as M/HM for dose ratio comparison, the median dose ratio for all HM-M rotations was 3.7 (2.9-4.5, lower-upper quartiles) vs. 5 (4.2-5.9) for M-HM rotations (P = 0.0001), suggesting that the opioid to which rotation is taking place is more potent than our proposed unified overall median dose ratio of 4.29:1 would predict. Our data suggests that HM is 5 times more potent than M when given second (M-HM), but is only 3.7 times more potent when given first (HM-M). We therefore recommend a ratio of 5 for M/HM in rotating from M to HM and ratio of 3.7 for M/HM when rotating from HM to M in patients exposed to chronic dosing of these opioids. There was no correlation observed between M-HM and HM-M dose ratios and the level of previous opioid dose, in contrast to HM to methadone rotation where the dose ratio was higher in patients receiving higher doses of HM.

Aged↗
PubMed1997

The Edmonton Functional Assessment Tool: preliminary development and evaluation for use in palliative care.

The purpose of this article is to report the development and psychometric testing of the Edmonton Functional Assessment Tool (EFAT). The EFAT was developed as a functional outcome measure for use with a palliative care population. The assessment identified ten functional activities important to patients even in the terminal stage of their illness. In addition, a global performance status rating (PS) asked for an overall judgment of functional status after the ten EFAT functions were evaluated. Tests for interrater reliability and concurrent validity were conducted on a sample of 25 inpatients on the Palliative Care Unit (PCU) at the Edmonton General Hospital (EGH) who were evaluated independently by two raters. Interrater reliability of the EFAT expressed as an intraclass correlation (ICC) was established at 0.88. The interrater reliability of these two raters was 0.71 for the Karnofsky Performance Status (KPS) and 0.81 for the performance status measure of the Eastern Cooperative Oncology Group (ECOG). Concurrent validity of the EFAT was demonstrated by correlating the total EFAT score with the KPS (r = -0.79, P = 0.0001) and the ECOG (r = 0.85, P = 0.0001). The total EFAT score was also strongly correlated with the global PS rating scale (r = 0.90, P = 0.0001). Construct validity of the EFAT was tested with a sample of 101 patients admitted to the unit, which was later divided into the unit group (N = 88) and the home group (N = 13). Our findings provided initial evidence that the EFAT distinguished between the functional status of these two groups. The results of this preliminary study suggest that the EFAT requires further research and development, but shows potential to evolve as a useful clinical tool in palliative care.

Aged↗
PubMed1997

Opioid availability in Latin America: the Santo Domingo report progress since the Declaration of Florianopolis.

The World Health Organization (WHO) has indicated that opioid analgesics are insufficiently available, particularly in developing countries, due to a variety of reasons, including legislative, educational, and policy issues. In its effort to promote the rational use of medical opioids and the adequate treatment of patients with cancer, WHO has sponsored a meeting of Latin American representatives every 2 years, which includes health professionals and government regulators. During March 24-27, 1996, a group of 86 representatives of cancer pain relief and palliative care programs from nine Latin American countries met in Santo Domingo under the auspices of the WHO Palliative Care Program for Latin America. For the first time since the First Latin American Meeting, government regulators were present to help address the issue of opioid availability from their perspective. During the meeting, issues pertaining to cancer pain, opioid availability, and palliative care were discussed. This report summarizes some of the events and presents a summary of the conclusions of an earlier meeting in 1994, as described in the Declaration of Florianopolis, and presents its follow-up, The Santo Domingo Report, generated following the 1996 meeting.

Analgesics, Opioid↗
PubMed1997

Dyspnea: pathophysiology and assessment.

Dyspnea is frequently a multicausal and devastating symptom among advanced cancer patients. It occurs in 21%-78.6% of patients days or weeks before death and is often difficult to control. The genesis and pathophysiology of dyspnea as a symptom still has not been well understood. Dyspnea is frequently associated with abnormalities in the mechanisms that regulate normal breathing; however, the actual expression of dyspnea by a patient results from a complex interaction between the abnormalities in breathing and the perception of those abnormalities in the central nervous system. The production of dyspnea has to be related to the activation of mechanoreceptors both in the respiratory muscles and in the lung, even in the absence of increased muscle respiratory activity. Respiratory muscle weakness appears to be an important cause of dyspnea in malnourished, asthenic, and cachectic cancer patients. This might also explain why about 24% of dyspneic cancer patients do not present cardiac/pulmonary disease. In addition, two other possible mechanisms of dyspnea have been proposed: chemoreceptor stimulation and efferent activity from the respiratory center by direct ascending stimulation. These factors and the assessment tools used in patients with chronic dyspnea are summarized in this review.

Disease Progression↗
PubMed1997

Successful management of multiple enterocutaneous fistulas in a patient with metastatic colon cancer.

Enterocutaneous fistula development is not uncommon in patients with advanced cancer and can be very challenging to manage. The authors present a case study of a patient with multiple enterocutaneous fistulas that developed in the setting of metastatic colon cancer. Assessment methods and interventions that permitted successful management are discussed with emphasis on the value of multidisciplinary care.

Colonic Neoplasms↗