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Biomedical subjects

E Bruera

Publications and source records attributed to E Bruera.

At least 163 records · Page 9Linked to original sources
PubMed1996

Volume of hydration in terminal cancer patients.

In this retrospective study we reviewed the volume and modality of hydration of consecutive series of terminal cancer patients in two different settings. In a palliative care unit 203/290 admitted patients received subcutaneous hydration for 12 +/- 8 days at a daily volume of 1015 +/- 135 ml/day. At the cancer center, 30 consecutive similar patients received intravenous hydration for 11.5 +/- 5 days (P > 0.2) but at a daily volume of 2080 +/- 720 ml/day (P < 0.001). None of the palliative care unit patients required discontinuation of hydration because of complications. Hypodermoclysis was administered mainly as a continuous infusion, an overnight infusion, or in one to three 1-h boluses in 62 (31%), 98 (48%) and 43 (21%) patients, respectively. Our findings suggest that, in some settings, patients may be receiving excessive volumes of hydration by less comfortable routes such as the intravenous route. Increased education and research in this area are badly needed.

Administration, Cutaneous↗
PubMed1996

Chronic nausea in advanced cancer patients: a retrospective assessment of a metoclopramide-based antiemetic regimen.

The purpose of this retrospective study is to assess the frequency and intensity of chronic nausea in patients admitted to the Palliative Care Unit and the results of a metoclopramide-based treatment regimen. We reviewed the medical records of 100 consecutive patients admitted to the Palliative Care Unit at the Edmonton General Hospital until death during 1992-1993. All patients had terminal cancer and normal cognitive function. All patients completed the Functional Analogue Scale for appetite, nausea, pain, activity, shortness of breath, and sensation of well-being at 1000 and 1600 hours every day. Patients who complained of nausea initially received metoclopramide 10 mg every 4 hr orally or subcutaneously (Step 1). If nausea persisted, dexamethasone 10 mg twice daily was added (Step 2). Step 3 consisted of a continuous subcutaneous infusion of metoclopramide of 60-120 mg/day plus dexamethasone. If no response was observed, other antiemetics were administered (Step 4). Upon admission to the unit, 32 patients (32%) presented with nausea. During the average admission of 25 +/- 13 days, 98 patients (98%) developed nausea. Twenty-five patients (25%) required other antiemetics because of bowel obstruction (18), extrapyramidal side effects (3), or other reasons (4). Most patients without bowel obstruction achieved excellent control of nausea using the metoclopramide-based regimen. During the first 5 days and last 5 days of admission, nausea had significantly lower intensity than the rest of the symptoms that were monitored. Our results suggest that, although nausea is very frequent, it can be well controlled in the majority of patients using safe and simple antiemetic regimens.

Aged↗
PubMed1996

Capsules and suppositories of methadone for patients on high-dose opioids for cancer pain: clinical and economic considerations.

The dose ratio, analgesic efficacy, toxicity and cost of methadone for cancer pain were evaluated in a retrospective review of 50 consecutive patients treated on a Palliative Care Unit. Patients were switched from hydromorphone 267.7 +/- 178.8 mg sc per day to custom-made capsules (24) or suppositories (26) of methadone for reasons of uncontrolled pain (24), toxicity (8), both (15) or other (2). The change in opioid occurred over 2.5 +/- 3.6 days, with another 4.4 +/- 3.7 days required to reach stable methadone dose. The ratio of stable methadone dose to final hydromorphone dose was 1.07 +/- 0.9 (oral) and 1.88 +/- 1.27 (rectal) (p = 0.01). Visual analogue scores for pain intensity (0-100 mm) declined from 50.8 +/- 22 to 40 +/- 20 (p = 0.01). The most frequent toxicities were constipation (46), sedation (42) and nausea (18). Six patients developed respiratory depression. Total cost of treatment was Canadian $116.77 +/- 157.17 for methadone capsules and Canadian $105.34 +/- 146.35 for methadone suppositories, vs Canadian $3450.51 +/- 5098.58 (p = 0.0001) for hydromorphone parenteral solution and Canadian $1801.21 +/- 2661.52 (p = 0.0001) for hydromorphone powder. It is concluded that methadone is an effective and inexpensive alternative in patients receiving high-dose opioids for cancer pain, at dose ratios much lower than recommended in the literature. The incidence of serious toxicities suggests that methadone should only be initiated in an adequately monitored setting by pain management experts.

Adult↗
PubMed1996

Guidelines on artificial nutrition versus hydration in terminal cancer patients. European Association for Palliative Care.

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step 1: define the eight key elements necessary to reach a decision; Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e., improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Fluid Therapy↗
PubMed1996

Rapid discontinuation of hypnotics in terminal cancer patients: a prospective study.

PURPOSE: To determine the proportion of patients receiving hypnotics upon admission to a palliative care unit, the frequency and intensity of withdrawal symptoms after rapid hypnotic discontinuation, and the effect of discontinuation on insomnia and cognitive failure. PATIENTS AND METHODS: 120 consecutive admitted patients. Rapid hypnotic discontinuation (1-4 days) was attempted. Insomnia (visual analogue 0 = best, 100 = worst for insomnia, restedness during the morning and difficulty falling asleep), cognition (Mini-Mental State Questionnaire), and withdrawal signs were monitored. RESULTS: Upon admission, 92/120 patients (77%) had been receiving hypnotics for a mean of 11 (standard deviation = 8) weeks. 4/92 patients (4%) refused hypnotic discontinuation. Acute mild withdrawal was observed in 2/88 patients (2%). The intensity of insomnia was not significantly different, while cognition significantly improved after hypnotic discontinuation. CONCLUSION: A large proportion of terminal cancer patients receives hypnotic drugs chronically. These drugs are probably not useful for the treatment of their insomnia, and rapid discontinuation can be safely achieved in most patients.

Adult↗
PubMed1996

Pain and Symptom Management in Palliative Care.

BACKGROUND: Pain, dyspnea, and anorexia are common symptoms experienced by patients with cancer and often are poorly managed. METHODS: The incidence and causes of these symptoms are described, as well as factors that exacerbate or ameliorate their impact. RESULTS: Pharmacologic management of cancer pain is based on the use of a sequential "ladder" that incorporates nonopioid, opioid, and adjuvant drugs, depending on the severity of the pain. This approach usually is effective. Other symptoms of advanced disease may be more difficult to control. CONCLUSIONS: Adherence to an adequate pain-control strategy will significantly enhance palliation of pain in patients with cancer.

Journal Article↗
PubMed1996

A randomized, double-blind, double-dummy, crossover trial comparing the safety and efficacy of oral sustained-release hydromorphone with immediate-release hydromorphone in patients with cancer pain. Canadian Palliative Care Clinical Trials Group.

PURPOSE: To evaluate the safety and efficacy of a new slow-release preparation of hydromorphone (SRH) in the treatment of cancer pain. PATIENTS AND METHODS: Ninety-five adult patients from three Canadian Palliative Care Centers with no evidence of mental impairment received treatment for cancer pain with an oral opioid analgesic. After informed consent was obtained, patients underwent titration to a stable dose of immediate-release hydromorphone (IRH) for 48 hours, and were then randomized to receive IRH or SRH for 5 days in a double-blind basis. During day 6, a crossover took place, and patients received the alternate drug for 5 days. Pain intensity was assessed using a visual analog scale (VAS) and ordinal scale (OS). Side effects were assessed using VAS. Patients and investigators made a blinded global rating of efficacy a blinded final choice between SRH and IRH. RESULTS: In 75 assessable patients, pain intensity of the VAS and OS were (mean +/- SD) 27 +/- 21 and 1.3 +/- 0.6 on IRH, versus 29 +/- 21 (P = .13) and 1.3 +/- 0.6 (P = .19) on SRH, respectively. The total number of extra doses of opioids, global rating, and final blinded choice by both patients and investigators were not significantly different between IRH and SRH. Differences in side effects were not significant. CONCLUSION: Our findings suggest that SRH is as safe and effective as IRH in the treatment of cancer pain.

Adult↗
PubMed1996

The role of palliative radiotherapy in advanced head and neck cancer.

The role of radiotherapy in the palliation of patients with advanced cancer of the head and neck is not clear. Several distinctive characteristics of advanced head and neck cancer contribute to the complexities in the choice of appropriate palliative management strategies. Palliative treatment may be the appropriate management for a proportion of patients with advanced disease, but the current stage groupings of head and neck cancer are not sufficient for use in the reliable identification of such a patient group. Controversy arises because of the difficulties in distinguishing patients who should be offered conventional treatment with curative intent from those appropriate for treatment with palliative intent. A structured review of the cancer and quality of life literature identified 298 references pertaining to palliative radiotherapy in head and neck cancer, 26 of which met the criteria for inclusion in this review. An expert panel discussed the literature, and concluded that insufficient information precluded estimations of the frequency, degree of, or duration of symptomatic relief that radiation offered to those patients not cured of their disease. Moreover, the currently available literature does not address the toxicity or appropriate dose and fractionation of palliative radiotherapy in this setting. Further studies are necessary to evaluate clinical endpoints appropriate to the use of radiotherapy in the palliative management of patients with advanced head and neck cancer. Studies are also needed to refine the current clinical classification of patients, allowing the identification of patients suitable for palliative management.

Clinical Trials as Topic↗
PubMed1996

Symptomatic hypocalcemia after intravenous pamidronate.

A 65-year-old woman admitted for palliative care of metastatic renal/bladder carcinoma developed symptomatic hypocalcemia nine days following a single dose of pamidronate. This may have implications for management of patients following discharge from hospital.

Aged↗
PubMed1996

Decreased opioid doses used on a palliative care unit.

We have previously published data on our use of opioids in the last week of life. A change in our pattern of opioid use, i.e. switching opioids more frequently and using high-dose methadone suppositories, appears to have resulted in a decrease in the number of patients requiring high-dose opioids. A retrospective chart review of 100 consecutive patients treated on our palliative care unit during 1992 was completed and compared to the original data from 1990. Results confirmed a decrease in the range of opioids used, as well as a statistically significant decrease in the daily opioid dose in the last week of life. We believe that this difference is most likely due to the use of methadone in patients showing either a poor response to other opioids or a rapid development to tolerance, as well as switching opioids more frequently to take advantage of incomplete cross-tolerance.

Aged↗
PubMed1995

Steady-state pharmacokinetic evaluation of a novel, controlled-release morphine suppository and subcutaneous morphine in cancer pain.

Although the oral route is the preferred method for morphine administration for cancer pain, many patients will require an alternate route of administration at some point during their illness. The authors studied the steady-state pharmacokinetics of morphine after administration of a novel, controlled-release suppository (MS-CRS) and subcutaneous morphine in a randomized, double-blind, two-way crossover evaluation in 10 patients with cancer pain. When administered at a 2.5:1 analgesic ratio, MS-CRS given every 12 hours showed an equivalent extent of absorption compared with subcutaneous morphine given every 4 hours (AUC0-12, 132.5 +/- 30.1 versus 123.8 +/- 27.3 ng.h.mL-1, P = not significant [NS]). Peak morphine concentrations were lower, time of peak was later, and percent fluctuation less after MS-CRS than after subcutaneous morphine (Cmax, 14.7 +/- 2.9 versus 29.9 +/- 5.4 ng/mL, P = .0110; tmax, 3.33 +/- 0.75 versus 2.22 +/- 0.15 hours, P = .0160; fluctuation, 122 +/- 71 versus 356 +/- 123%, P = .00160). Relative bioavailability of MS-CRS using the 2.5:1 analgesic ratio was 105%, and bioavailability from data dose normalized without regard to route specificity in metabolism was 42%. For both routes of administration there was a significant linear relationship between morphine dose and AUC (MS-CRS, r = .8568, P = .0032; subcutaneous morphine, r = .8314, P = .0055). MS-CRS morphine provides a pharmacokinetic profile consistent with dosing every 12 hours; at steady state, the extent of absorption is comparable with that of subcutaneous morphine when administered at a 2.5:1 dose ratio.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗