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Biomedical subjects

P A Glare

Publications and source records attributed to P A Glare.

At least 19 recordsLinked to original sources
PubMed2001

Can we do better in end-of-life care? The mixed management model and palliative care.

The increasing duration of life from disease diagnosis to death in cancer and chronic non-malignant illnesses argues for a revised approach to end-of-life care that incorporates the principles of palliative care from an earlier stage (ie, a stage at which curative and/or life-prolonging treatments are still being provided). The provision of active treatment and comfort measures/death preparation in parallel has been called the "mixed management model" of end-of life care.

Australia↗
PubMed2001

Pain in patients with HIV infection: issues for the new millennium.

Pain is a common problem in people infected with the human immunodeficiency virus (HIV), particularly when they develop the acquired immune deficiency syndrome (AIDS). Until recently AIDS was a progressive fatal illness with a short prognosis, so the assessment and treatment of AIDS-related pain was logically based on the approach taken for the management of cancer pain. The cancer pain paradigm may no longer be appropriate for pain in patients with HIV infection, however, because the natural history of HIV disease has been transformed into a chronic illness by highly active anti-retroviral therapy (HAART), available since the late 1990s. In resource-poor countries of the Asia Pacific region where access to HAART is limited, the cancer pain paradigm may still be relevant. In this paper, the clinical characteristics of pain in HIV disease are described, along with current approaches to assessment and treatment. These are compared and contrasted with the characteristics, assessment and treatment of cancer pain. Data are presented which emphasize these similarities and differences, and highlight the need for a multidisciplinary, comprehensive approach to managing pain in HIV disease, now a chronic illness. There is a great need for more research on HIV-related pain in the HAART era.

Developing Countries↗
PubMed1997

A prospective, within-patient, crossover study of continuous intravenous and subcutaneous morphine for chronic cancer pain.

The dose, efficacy, and side effects of continuous intravenous infusion (CIVI) of morphine were compared with continuous subcutaneous infusion (CSCI) of morphine in patients with chronic cancer pain. Eligible patients were referred to the Palliative Care Program and were receiving a stable dose of CIVI of morphine. The design was a within-patient, one-way crossover; in which each patient provided data before and after a switch from CIVI to CSCI of morphine. "Rescue" doses were 50% of the hourly dose given every 2 hours as needed. Morphine was infused intravenously (i.v.) and subcutaneously (s.c.) via a McGaw/AccuPro Volumetric Infusion Pump. After baseline data, including side effects and pain assessment, were obtained, patients were evaluated twice daily for toxicity and analgesic efficacy. Those who had a stable CIVI dose for 48 consecutive hr were crossed over to the CSCI at the same dose as the intravenous (i.v.) phase. A stable dose was defined as no dose change, four or less rescue doses in the previous 24 hr, and a pain rating of none or mild. CIVI was considered equal to CSCI if these criteria were maintained for 96 consecutive hr. Fifty-seven patients were entered, and 40 were evaluable (15 women and 25 men). The median age was 67 (range 30-83 years). All 40 participants, after maintaining a stable dose throughout the i.v. phase, crossed to the s.c. phase and remained on s.c. for at least 48 hr. Thirty-two patients maintained a stable dose throughout the i.v. and s.c. phases. The mean stable i.v. dose (day 2) was 5.05 mg/hr, and the mean stable s.c. dose (day 4) was 5.7 mg/hr (P = 0.01). The mean number of rescue doses on day 2 was 0.83 per 24 hr versus 0.80 per 24 hours on day 4 (P = 0.6). The mean categorical pain score on day 2 was 0.83, and on day 4, 0.85 (P = 0.7). The mean visual analogue scale (VAS) on day 2 was 22.9 mm versus 17.6 mm on day 4 (P = 0.1). The mean incidence of side effects on day 2 was 1.7, and on day 4, 2.0 (P = 0.2). No patient was withdrawn or had a dose reduction due to unacceptable toxicity. There were two reports of local toxicity (mild erythema) at the SC needle insertion point, which required a site change. All of our 40 patients had adequate pain control with CIVI and CSCI morphine. Of the eight participants who were not maintained on the same i.v. and s.c. dose, all had adequate pain control and a similar side-effect profile on a higher s.c. morphine dose. These data suggest that the i.v. and s.c. routes are equianalgesic for most patients when administered as a continuous infusion. Pain control and side-effect profiles are quite similar and acceptable. s.c. morphine is an excellent alternative to i.v. morphine in both inpatients and outpatients requiring parenteral morphine for pain.

Adult↗
PubMed1997

Contribution of a liaison clinical pharmacist to an inpatient palliative care unit.

The impact on patient care of interventions made by a liaison clinical pharmacist visiting a busy inpatient palliative care unit were evaluated using a validated six-point scoring system. Interventions made in 13% of patients could improve patient care, save money or both, but rarely involved the drugs that are commonly used for symptom control in patients with terminal cancer. Advice to rationalize inappropriate drug regimens (53%) was the commonest intervention, followed by warnings about drug interactions (24%) and advice about therapeutic drug monitoring (8%). The interventions were evaluated by the pharmacist, a palliative medicine registrar and two independent doctors, confirming that the pharmacist was valid and accurate in assessing her own work. Although more than 60% of interventions could significantly improve patient care, compliance by medical and nursing staff with advice was only 55%, reflecting possible tensions between palliative and general hospital medicine. This survey emphasizes the role of liaison clinical pharmacists in palliative care, the need for much more critical appraisal of prescribing practices and the utility of ranking pharmacist interventions as a quality assurance and educational tool. In particular, providing palliative care for patients with advanced acquired immunodeficiency syndrome (AIDS) is enhanced when a pharmacist with a specialist knowledge of AIDS therapeutics is available.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Palliative care in acquired immunodeficiency syndrome (AIDS): problems and practicalities.

The World Health Organisation estimates that over 1.5 million human immunodeficiency virus (HIV) infections have occurred to date in South and South East Asia. As most of these patients will develop acquired immunodeficiency syndrome (AIDS) in the coming decade, health services in the region face a major challenge in meeting their needs. While treatments are available which prolong the lives of patients with AIDS, most will eventually die of their disease, and attention needs to be given to controlling pain and other symptoms and improving quality of life. Providing palliative care for patients with AIDS raises complex issues not normally encountered in traditional palliative care practice. Based on the author's experience with the Central Sydney Area Palliative Care Service in Sydney, Australia, this paper discusses the problems and practicalities involved in palliative care for adult patients with advanced AIDS, such as clinical decision making, pain and other symptom control, psychosocial issues and terminal care. Representative case histories are described to illustrate how the palliative care physician can start to approach some of the dilemmas created by this demanding yet growing area of palliative care.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Central Sydney Palliative Care Service: potential and limitations of an integrated palliative care service based in a metropolitan teaching hospital.

Palliative care needs to be available wherever needed, in hospital and home, and should be part of mainstream health care. Palliative care should be concurrent with anti-disease therapy, and includes but goes beyond "terminal care". The World Health Organization (WHO) encourages such development. Palliative care in Australia takes on many forms. Central Sydney Palliative Care Service based in Royal Prince Alfred Hospital (RPAH), Camperdown, is an example of mainstream palliative care integrating home and hospital care. Almost all units of RPAH refer patients to the palliative care service. Approximately 1000 new patients are referred annually by doctors (specialists or general practitioners) for medical consultation. Registrar (fellow) training in palliative medicine is a feature of the service. Palliative care in a hospital or community-based service is an issue of justice and equity, and gives structure to compassion.

Adolescent↗
PubMed1993

Dose-ranging study of oxycodone for chronic pain in advanced cancer.

PURPOSE AND METHODS: We assessed the analgesic efficacy and safety of single-entity oxycodone solution at doses greater than 10 mg orally every 4 hours in 24 patients with chronic cancer pain not controlled by weaker analgesics. RESULTS: Twenty of 24 patients completed the study. Pain relief was obtained with doses up to 60 mg every 4 hours. When oxycodone was taken for long periods, further dose increments could be made safely. The side effects of oxycodone are mild, and common to all opioids, with sedation and constipation most frequent. Nausea was more common in females in all age groups and in patients of either sex less than 50 years of age. Episodes of serious toxicity were rare, and responded to dose reduction. Patients older than 65 years required lower doses, suggesting pharmacokinetic similarities between oxycodone and morphine. Patients changed from oral oxycodone to morphine remained pain-free when relative milligram potency ratios of 1:1 to oral morphine and 3:1 to intravenous morphine were used. CONCLUSION: Oxycodone has been shown for the first time to be as versatile and flexible as oral morphine in the management of chronic pain in patients with advanced cancer.

Adult↗
PubMed1991

Clinical pharmacokinetics of morphine.

Morphine (M) is recommended by the World Health Organization as the treatment of choice for moderate-to-severe cancer pain. Development of sensitive radioimmunoassays (RIA) and high-performance liquid chromatography in the past 20 years has allowed study of the pharmacokinetics of M, which remain incompletely understood. Data derived by RIA must be interpreted with caution due to cross-reactivity with anti-sera by metabolites, impairing assay specificity. The pharmacokinetics of M have been determined for various clinical situations, but there is large interpatient variability for most parameters. M is readily absorbed from all routes of administration, except transdermal, and it can be injected spinally. Peak plasma levels are achieved within 15-20 min of intramuscular and subcutaneous administration, and within 30-90 min after oral. Peak levels after oral administration are much lower than after parenteral routes, since oral M undergoes extensive first-pass metabolism in the liver. With repeated administration, the oral-parenteral relative potency ratio is 1:3 M can be administered epidurally or intrathecally and has also been given intracerebroventricularly. Epidural M enters the subarachnoid space, but is also absorbed into the systemic circulation. Only 5% of a dose crosses the dura. M administered in the lumbar region is quickly redistributed in the cerebrospinal fluid in a rostral direction, explaining the high incidence of systemic side effects following spinal administration. After absorption, M is rapidly and widely distributed and crosses the blood-brain barrier. With therapeutic doses, plasma protein binding is only 20-35%, and the volume of distribution is 1-6 L/kg. The primary site of M metabolism is the liver, and the dose should be reduced in patients with liver disease. Glucuronidation is the main metabolic pathway, but the principal metabolite, morphine-3-glucuronide (M3G), is inactive. Morphine-6-glucuronide (M6G) is produced in smaller amounts than M3G, but is pharmacologically active and many times more potent than M. The ratio of M6G to M in plasma, after a dose of M, is approximately 10:1, and the ratio does not change with increasing doses or prolonged treatment. Normorphine (NM) is also active, and is formed to a greater extent after oral administration; it is not, however, usually found in plasma. NM may be neurotoxic. M and its metabolites are excreted by the kidney, but urinary free M accounts for less than 10% of an administered dose. In patients with renal insufficiency, the metabolites accumulate, though M itself is still excreted.(ABSTRACT TRUNCATED AT 400 WORDS)

Biotransformation↗
PubMed1991

A simple, rapid method for the simultaneous determination of morphine and its principal metabolites in plasma using high-performance liquid chromatography and fluorometric detection.

This article describes a high-performance liquid chromatography (HPLC) method for the simultaneous determination of morphine (M) and its principal metabolites morphine-3-glucuronide (M3G), morphine-6-glucuronide (M6G), and normorphine (NM) in plasma. All four compounds are extracted from plasma using a C8 solid-phase extraction column, separated by reverse-phase HPLC on a C18 analytical column, and detected by spectrofluorometry at 210 nm excitation wavelength. The method takes advantage of the compounds' native fluorescence, so that derivitization is not required. Samples have been quantified over a concentration range of 25-100 ng/ml M and NM, 50-200 ng/ml M3G, and 100-300 ng/ml M6G, using nalorphine (500 ng/ml) as internal standard. Within-run and between-run errors were less than 10% for morphine and less than 13% for all the metabolites. The lower limit of quantitation for morphine is 10 ng/ml. The accuracy of the method was confirmed by including quality controls fitted to the standard curves of each compound. The assay described in this article represents a simplification of previous versions of the method, which included cumbersome extraction procedures and multiple detectors. For the first time, an internal standard has been employed. The assay is reliable and easy to use and can be performed in any therapeutic drug monitoring laboratory.

Chromatography, High Pressure Liquid↗