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Haugdahl HS, Storli SL, Meland B, Dybwik K, Romild U, Klepstad P. Reply: Assessment of Intensive Care Unit Patients' Experience of Breathlessness. Am J Respir Crit Care Med 2017; 193:1439-41. [PMID: 27304248 DOI: 10.1164/rccm.201603-0655le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hege S Haugdahl
- 1 UiT The Arctic University of Norway Tromsø, Norway.,2 Nord-Trøndelag Hospital Trust Levanger, Norway.,3 Nord University Levanger, Norway
| | | | | | - Knut Dybwik
- 5 Nordland Hospital Bodø, Norway.,6 Nord University Bodø, Norway
| | - Ulla Romild
- 2 Nord-Trøndelag Hospital Trust Levanger, Norway.,7 Public Health Agency of Sweden Östersund, Sweden and
| | - Pål Klepstad
- 4 St. Olav University Hospital Trondheim, Norway.,8 Norwegian University of Science and Technology Trondheim, Norway
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52
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Seternes A, Rekstad LC, Mo S, Klepstad P, Halvorsen DL, Dahl T, Björck M, Wibe A. Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival. World J Surg 2017; 41:152-161. [PMID: 27541031 DOI: 10.1007/s00268-016-3694-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. METHODS Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. RESULTS The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. CONCLUSION Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.
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Affiliation(s)
- A Seternes
- Departments of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway. .,Departments of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway. .,Departments of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7006, Trondheim, Norway.
| | - L C Rekstad
- Departments of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway
| | - S Mo
- Departments of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway
| | - P Klepstad
- Departments of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway.,Departments of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7006, Trondheim, Norway
| | - D L Halvorsen
- Departments of Urologic Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway
| | - T Dahl
- Departments of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway.,Departments of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7006, Trondheim, Norway
| | - M Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 751 85, Uppsala, Sweden
| | - A Wibe
- Departments of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7006, Trondheim, Norway.,Departments of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
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53
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Schirmer-Mikalsen K, Vik A, Skogvoll E, Moen KG, Solheim O, Klepstad P. Intracranial Pressure During Pressure Control and Pressure-Regulated Volume Control Ventilation in Patients with Traumatic Brain Injury: A Randomized Crossover trial. Neurocrit Care 2017; 24:332-41. [PMID: 26503512 DOI: 10.1007/s12028-015-0208-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Mechanical ventilation with control of partial arterial CO2 pressures (PaCO2) is used to treat or stabilize intracranial pressure (ICP) in patients with traumatic brain injury (TBI). Pressure-regulated volume control (PRVC) is a ventilator mode where inspiratory pressures are automatically adjusted to deliver the patient a pre-set stable tidal volume (TV). This may result in a more stable PaCO2 and thus a more stable ICP compared with conventional pressure control (PC) ventilation. The aim of this study was to compare PC and PRVC ventilation in TBI patients with respect to ICP and PaCO2. METHODS This is a randomized crossover trial including eleven patients with a moderate or severe TBI who were mechanically ventilated and had ICP monitoring. Each patient was administered alternating 2-h periods of PC and PRVC ventilation. The outcome variables were ICP and PaCO2. RESULTS Fifty-two (26 PC, 26 PRVC) study periods were included. Mean ICP was 10.8 mmHg with PC and 10.3 mmHg with PRVC ventilation (p = 0.38). Mean PaCO2 was 36.5 mmHg (4.87 kPa) with PC and 36.1 mmHg (4.81 kPa) with PRVC (p = 0.38). There were less fluctuations in ICP (p = 0.02) and PaCO2 (p = 0.05) with PRVC ventilation. CONCLUSIONS Mean ICP and PaCO2 were similar for PC and PRVC ventilation in TBI patients, but PRVC ventilation resulted in less fluctuation in both ICP and PaCO2. We cannot exclude that the two ventilatory modes would have impact on ICP in patients with higher ICP values; however, the similar PaCO2 observations argue against this.
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Affiliation(s)
- Kari Schirmer-Mikalsen
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway. .,Department of Anaesthesiology and Intensive Care Medicine, St. Olav University Hospital, Pb 3250 Sluppen, 7006, Trondheim, Norway.
| | - Anne Vik
- Department of Neurosurgery, St. Olav University Hospital, Pb 3250 Sluppen, 7006, Trondheim, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Eirik Skogvoll
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway.,Department of Anaesthesiology and Intensive Care Medicine, St. Olav University Hospital, Pb 3250 Sluppen, 7006, Trondheim, Norway
| | - Kent Gøran Moen
- Department of Neuroscience, Norwegian University of Science and Technology, 7491, Trondheim, Norway.,Department of Medical Imaging, St. Olav University Hospital, Pb 3250 Sluppen, 7006, Trondheim, Norway
| | - Ole Solheim
- Department of Neurosurgery, St. Olav University Hospital, Pb 3250 Sluppen, 7006, Trondheim, Norway.,Department of Neuroscience, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway.,Department of Anaesthesiology and Intensive Care Medicine, St. Olav University Hospital, Pb 3250 Sluppen, 7006, Trondheim, Norway
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Raj SX, Brunelli C, Klepstad P, Kaasa S. COMBAT study - Computer based assessment and treatment - A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients. Scand J Pain 2017; 17:99-106. [PMID: 28850380 DOI: 10.1016/j.sjpain.2017.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 06/12/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS The prevalence of pain in cancer patients are relatively high and indicate inadequate pain management strategies. Therefore, it is necessary to develop new methods and to improve implementation of guidelines to assess and treat pain. The vast improvement in information technology facilitated development of a computerized symptom assessment and decision support system (CCDS) - the Combat system - which was implemented in an outpatient cancer clinic to evaluate improvement in pain management. METHODS We conducted a controlled before-and-after study between patient cohorts in two consecutive study periods: before (n=80) and after (n=134) implementation of the Combat system. Patients in the first cohort completed questionnaires with the paper-and-pencil method and this data was not shown to physicians. Patients in the latter cohort completed an electronic questionnaire by using an iPad and the data were automatically transferred and presented to physicians at point of care. Additionally, the system provided computerized decision support at point of care for the physician based on the electronic questionnaires completed by the patients, an electronic CRF completed by physicians and clinical guidelines. RESULTS The Combat system did not improve pain intensity and there were no significant alterations in the prescribed dose of opiates compared to the cohort of patients managed without the Combat system. CONCLUSION The Combat system did not improve pain management. This may be explained by several factors, however, we consider lack of proper implementation of the CCDS in the clinic to be the most important factor. As a result, we did not manage to change the behaviour of the physicians in the clinic. IMPLICATIONS There is a need to conduct larger prospective studies to evaluate the efficacy of modern information technology to improve pain management in cancer patients. Before introducing new information technology in the clinics, it is important to have a well thought out implementation strategy. The trial is registered at Clinialtrials.gov, number NCT01795157.
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Affiliation(s)
- Sunil X Raj
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Pål Klepstad
- Department of Anaesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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55
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Haugdahl HS, Dahlberg H, Klepstad P, Storli SL. The breath of life. Patients' experiences of breathing during and after mechanical ventilation. Intensive Crit Care Nurs 2017; 40:85-93. [PMID: 28341400 DOI: 10.1016/j.iccn.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Breathlessness is a prevalent and distressing symptom in intensive care, underestimated by nurses and physicians. Therefore, to develop a more comprehensive understanding of this problem, the study had two aims: to compare patients' self-reported scores of breathlessness obtained during mechanical ventilation (MV) with experiences of breathlessness later recalled by patients and: to explore the lived experience of breathing during and after MV. METHOD A qualitatively driven sequential mixed method design combining prospective observational breathlessness data at the end of a spontaneous breathing trial (SBT) and follow up data from 11 post-discharge interviews. FINDINGS Four out of six patients who reported breathlessness at the end of an SBT did not remember being breathless in retrospect. Experiences of breathing intertwined with the whole illness experience and were described in four themes: existential threat; the tough time; an amorphous and boundless body and getting through. CONCLUSION Breathing was not always a clearly separate experience, but intertwined with the whole illness experience. This may explain the poor correspondence between patients' and clinicians assessments of breathlessness. The results suggest patients' own reports of breathing should form part of nursing interventions and follow-up to support patients' quest for meaning.
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Affiliation(s)
- Hege S Haugdahl
- UiT The Arctic University of Norway, Tromsø, Norway; Nord University, Levanger, Norway; Nord-Trøndelag Hospital Trust, Levanger, Norway.
| | | | - Pål Klepstad
- St. Olav University Hospital, Trondheim, Norway; Norwegian University of Science and Technology, Trondheim, Norway
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Uleberg O, Kristiansen T, Pape K, Romundstad PR, Klepstad P. Trauma care in a combined rural and urban region: an observational study. Acta Anaesthesiol Scand 2017; 61:346-356. [PMID: 28111748 DOI: 10.1111/aas.12856] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/17/2016] [Accepted: 12/29/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND The available information on trauma care in mixed rural-urban areas with scattered populations is limited. The aim of this study is to describe epidemiology, resource use, transfers and outcomes for trauma care within such an area, prior to implementation of a formal trauma system. METHODS A multicentre observational study including potential severely injured patients from June 2007 to May 2010. All patients received by trauma teams at seven acute care hospitals (ACH) and one major trauma centre (MTC) were included. Major trauma was defined as Injury Severity Score (ISS) > 15. RESULTS A total of 2323 patients were included. ACH received 1330 patients and delivered definite care to 85% of these. Only 329 (14%) patients were major trauma of which 134 (41%) were initially received at an ACH. Nine per cent of patients were transferred between hospitals. After inter-hospital transfers, 79% of all major trauma patients received definite care at the MTC. Helicopter emergency services admitted 52% of major trauma and performed 68% of inter-hospital transfers from ACH to MTC. Forty-eight patients (2%) died within 30 days. CONCLUSION In a region with a dispersed network of hospitals, geographical challenges, and low rate of major trauma cases, efforts should be made to identify patients with major trauma for treatment at a MTC as early as possible. This can be done by implementing triage and transfer guidelines, maintaining competence at ACHs for initial stabilization, and sustaining an organization for effective inter-facility transfers.
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Affiliation(s)
- O. Uleberg
- Department of Emergency Medicine and Pre-Hospital Services; St. Olav's University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Faculty of medicine; NTNU; Norwegian University of Science and Technology; Trondheim Norway
| | - T. Kristiansen
- Department of Anaesthesiology; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo Norway
| | - K. Pape
- Department of Public Health; Faculty of medicine; NTNU; Norwegian University of Science and Technology; Trondheim Norway
| | - P. R. Romundstad
- Department of Public Health; Faculty of medicine; NTNU; Norwegian University of Science and Technology; Trondheim Norway
| | - P. Klepstad
- Department of Circulation and Medical Imaging; Faculty of medicine; NTNU; Norwegian University of Science and Technology; Trondheim Norway
- Department of Anaesthesiology and Intensive Care Medicine; St. Olav's University Hospital; Trondheim Norway
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Haugland H, Rehn M, Klepstad P, Krüger A. Developing quality indicators for physician-staffed emergency medical services: a consensus process. Scand J Trauma Resusc Emerg Med 2017; 25:14. [PMID: 28202076 PMCID: PMC5311851 DOI: 10.1186/s13049-017-0362-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 02/10/2017] [Indexed: 12/24/2022] Open
Abstract
Background There is increasing interest for quality measurement in health care services; pre-hospital emergency medical services (EMS) included. However, attempts of measuring the quality of physician-staffed EMS (P-EMS) are scarce. The aim of this study was to develop a set of quality indicators for international P-EMS to allow quality improvement initiatives. Methods A four-step modified nominal group technique process (expert panel method) was used. Results The expert panel reached consensus on 26 quality indicators for P-EMS. Fifteen quality indicators measure quality of P-EMS responses (response-specific quality indicators), whereas eleven quality indicators measure quality of P-EMS system structures (system-specific quality indicators). Discussion When measuring quality, the six quality dimensions defined by The Institute of Medicine should be appraised. We argue that this multidimensional approach to quality measurement seems particularly reasonable for services with a highly heterogenic patient population and complex operational contexts, like P-EMS. The quality indicators in this study were developed to represent a broad and comprehensive approach to quality measurement of P-EMS. Conclusions The expert panel successfully developed a set of quality indicators for international P-EMS. The quality indicators should be prospectively tested for feasibility, validity and reliability in clinical datasets. The quality indicators should then allow for adjusted quality measurement across different P-EMS systems. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0362-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Helge Haugland
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Department of Emergency Medicine and Pre-Hospital Services, St. Olavs Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway.,Division of Emergencies and Critical Care. Department of Anaesthesia, Oslo University Hospital, Oslo, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anaesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway
| | - Andreas Krüger
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St. Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
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Dale O, Klepstad P, Tveita T, Thoner J, Borchgrevink PC. Re: Fra ketobemidon til oksykodon. Tidsskriftet 2017; 137:423. [DOI: 10.4045/tidsskr.17.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Løhre ET, Klepstad P, Bennett MI, Brunelli C, Caraceni A, Fainsinger RL, Knudsen AK, Mercadante S, Sjøgren P, Kaasa S. Authors' Reply to Davies et al. J Pain Symptom Manage 2016; 52:e1-e2. [PMID: 27693897 DOI: 10.1016/j.jpainsymman.2016.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/29/2016] [Indexed: 11/22/2022]
Affiliation(s)
- Erik T Løhre
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Pål Klepstad
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Michael I Bennett
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Cinzia Brunelli
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Augusto Caraceni
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Robin L Fainsinger
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Anne K Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Sebastiano Mercadante
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Per Sjøgren
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Skorpen F, von Hofacker S, Bjørngaard M, Skogholt AH, Dale O, Kaasa S, Klepstad P. The rare Arg181Cys mutation in the μ opioid receptor can abolish opioid responses. Acta Anaesthesiol Scand 2016; 60:1084-91. [PMID: 27113810 DOI: 10.1111/aas.12739] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/07/2016] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Genetic variability contributes to variable clinical response to opioids. This study emerged from the observation of three Norwegian patients who showed no or extraordinary poor response to very high doses of opioids. We suspected a genetic defect and applied a 'most likely candidate gene' approach to investigate this possibility. METHODS DNA sequencing was used to search for mutations in coding regions of the OPRM1 gene, encoding the μ opioid receptor (hMOR), in one patient. The remaining two patients, and two cohorts comprising 2158 European cancer pain patients and 600 Norwegian healthy volunteers, respectively, were genotyped using a custom-made TaqMan SNP allelic discrimination assay. RESULTS DNA sequencing disclosed a homozygous, inactivating Arg181Cys mutation in hMOR in the patient who showed no effects from opioids. The two patients with poor effect from very high doses of opioids were both heterozygous for the mutation. Six heterozygous patients identified among the European cancer patients all used high doses of opioids and/or reported inferior effect on their pain. About one in every 100 Norwegians is heterozygous for the mutation. CONCLUSIONS The Arg181Cys mutation occurs at clinically relevant frequencies and produces a signaling dead hMOR which may abolish or significantly reduce opioid effects in affected individuals. Anesthesiologists and practitioners in pain medicine should be aware of this mutation as a possible explanation for inefficiency of opioids and consider genotyping in relevant cases. Individuals homozygous for the mutation may need a highly personalized approach to pain therapy.
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Affiliation(s)
- F. Skorpen
- Department of Laboratory Medicine; Children's and Women's Health; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- European Palliative Care Research Center; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - S. von Hofacker
- Regional Centre of Excellence for Palliative Care, Western Norway; Haukeland University Hospital; Bergen Norway
- Sunniva Centre for Palliative Care; Haraldsplass Deaconess Hospital; Bergen Norway
| | - M. Bjørngaard
- Department of Anaesthesiology and Intensive Care Medicine; Volda Hospital; Volda Norway
| | - A. H. Skogholt
- Department of Laboratory Medicine; Children's and Women's Health; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - O. Dale
- Department of Research and Innovation; St. Olav's University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - S. Kaasa
- European Palliative Care Research Center; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Department of Oncology; St Olav's University Hospital; Trondheim Norway
| | - P. Klepstad
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
- Department of Anaesthesiology and Intensive Care Medicine; St Olav's University Hospital; Trondheim Norway
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61
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Gjeilo KH, Stenseth R, Wahba A, Lydersen S, Klepstad P. Chronic postsurgical pain in patients 5 years after cardiac surgery: A prospective cohort study. Eur J Pain 2016; 21:425-433. [PMID: 27461370 DOI: 10.1002/ejp.918] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chronic postsurgical pain (CPSP) is a common complication after many surgical procedures, including cardiac surgery. The prevalence of CPSP after cardiac surgery ranges from 9.5% to 56%. Most studies on CPSP after cardiac surgery are retrospective and long-term prospective studies are scarce. The aim of this study was to follow CPSP and health-related quality of life (HRQOL) prospectively in a cohort of patients, emphasizing the prevalence from 12 months to 5 years. METHODS A total of 534 patients (23% ≥75 years, 67% men) were consecutively included before surgery. Study-specific questionnaires and the Brief Pain Inventory (BPI) were used to measure CPSP at baseline, 12 months and 5-year follow-up. Short-Form Health Survey (SF-36) was used to measure HRQOL. RESULTS Among 458 patients who were alive after 5 years, 82% responded (n = 373). The majority, 89.8% (335/373), did not report CPSP, neither 12 months nor 5 years after surgery. Among the 38 patients who reported CPSP after 12 months, 24 (63%) patients did not report CPSP after 5 years. The overall prevalence of CPSP after 5 years was 3.8% (14/373). Patients reporting CPSP and resolved CPSP had lower scores on HRQOL and more pain preoperatively than patients who did not report CPSP. CONCLUSIONS The prevalence of CPSP was lower in this study than previously reported. Among the patients reporting CPSP at 12 months, 63% did not report CPSP after 5 years. Hence, the observed decline in CPSP is in line with studies evaluating CPSP in noncardiac surgery. SIGNIFICANCE The prevalence of chronic postsurgical pain (CPSP) at 5 years after surgery of 3.8% is lower than previously reported. The majority of patients reporting CPSP after 12 months did not report CPSP after 5 years.
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Affiliation(s)
- K H Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Norway.,Department of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Norway.,National Competence Centre for Complex Symptom Disorders, St. Olavs Hospital, Trondheim University Hospital, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - R Stenseth
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Cardiothoracic Anaesthesiology, St. Olavs Hospital, Trondheim University Hospital, Norway
| | - A Wahba
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - S Lydersen
- Regional Centre for Child and Youth Mental Health and Child Welfare-Central Norway, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - P Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Norway
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Kurita GP, Ekholm O, Kaasa S, Klepstad P, Skorpen F, Sjøgren P. Genetic variation and cognitive dysfunction in opioid-treated patients with cancer. Brain Behav 2016; 6:e00471. [PMID: 27247849 PMCID: PMC4864175 DOI: 10.1002/brb3.471] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 03/10/2016] [Accepted: 03/11/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND PURPOSE The effects of single-nucleotide polymorphisms (SNPs) on the cognitive function of opioid-treated patients with cancer until now have not been explored, but they could potentially be related to poor functioning. This study aimed at identifying associations between SNPs of candidate genes, high opioid dose, and cognitive dysfunction. METHODS Cross-sectional multicenter study (European Pharmacogenetic Opioid Study, 2005-2008); 1586 patients; 113 SNPs from 41 genes. INCLUSION CRITERIA cancer, age ≥18 year, opioid treatment, and available genetic data. Cognitive assessment by Mini-Mental State Examination (MMSE). ANALYSES SNPs were rejected if violation of Hardy-Weinberg equilibrium (P < 0.0005), or minor allele frequency <5%; patients were randomly divided into discovery sample (2/3 for screening) and validation sample (1/3 for confirmatory test); false discovery rate of 10% for determining associations (Benjamini-Hochberg method). Co-dominant, dominant, and recessive models were analyzed by Kruskal-Wallis and Mann-Whitney tests. RESULTS In the co-dominant model significant associations (P < 0.05) between MMSE scores and SNPs in the HTR3E,TACR1, and IL6 were observed in the discovery sample, but the replication in the validation sample did not confirm it. Associations between MMSE scores among patients receiving ≥400 mg morphine equivalent dose/day and SNPs in TNFRSF1B,TLR5,HTR2A, and ADRA2A were observed, but they could not be confirmed in the validation sample. After correction for multiple testing, no SNPs were significant in the discovery sample. Dominant and recessive models also did not confirm significant associations. CONCLUSIONS The findings did not support influence of those SNPs analyzed to explain cognitive dysfunction in opioid-treated patients with cancer.
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Affiliation(s)
- Geana Paula Kurita
- Multidisciplinary Pain Centre Department of Neuroanaesthesiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark; Department of Oncology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Ola Ekholm
- National Institute of Public Health University of Southern Denmark Copenhagen Denmark
| | - Stein Kaasa
- Department of Oncology Oslo University Hospital/University of Oslo Norway; European Palliative Care Research Centre Faculty of Medicine Norwegian University of Science and Technology Trondheim Norway
| | - Pål Klepstad
- Department of Intensive Care Medicine St Olavs Hospital Trondheim University Hospital Trondheim Norway; Department of Circulation and Medical Imaging Norwegian University of Science and Technology Norway
| | - Frank Skorpen
- Department of Laboratory Medicine Children's and Women's Health Norwegian University of Science and Technology Trondheim Norway
| | - Per Sjøgren
- Section of Palliative Medicine Department of Oncology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark; Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
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63
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Laird BJA, Fallon M, Hjermstad MJ, Tuck S, Kaasa S, Klepstad P, McMillan DC. Quality of Life in Patients With Advanced Cancer: Differential Association With Performance Status and Systemic Inflammatory Response. J Clin Oncol 2016; 34:2769-75. [PMID: 27354484 DOI: 10.1200/jco.2015.65.7742] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Quality of life is a key component of cancer care; however, the factors that determine quality of life are not well understood. The aim of this study was to examine the relationship between quality of life parameters, performance status (PS), and the systemic inflammatory response in patients with advanced cancer. METHODS An international biobank of patients with advanced cancer was analyzed. Quality of life was assessed at a single time point by using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C-30 (EORTC QLQ-C30). PS was assessed by using the Eastern Cooperative Oncology Group (ECOG) classification. Systemic inflammation was assessed by using the modified Glasgow Prognostic Score (mGPS), which combines C-reactive protein and albumin. The relationship between quality of life parameters, ECOG PS, and the mGPS was examined. RESULTS Data were available for 2,520 patients, and the most common cancers were GI (585 patients [22.2%]) and pulmonary (443 patients [17.6%]). The median survival was 4.25 months (interquartile range, 1.36 to 12.9 months). Increasing mGPS (systemic inflammation) and deteriorating PS were associated with deterioration in quality-of-life parameters (P < .001). Increasing systemic inflammation was associated with deterioration in quality-of-life parameters independent of PS. CONCLUSION Systemic inflammation was associated with quality-of-life parameters independent of PS in patients with advanced cancer. Further investigation of these relationships in longitudinal studies and investigations of possible effects of attenuating systemic inflammation are now warranted.
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Affiliation(s)
- Barry J A Laird
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom.
| | - Marie Fallon
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom
| | - Marianne J Hjermstad
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom
| | - Sharon Tuck
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom
| | - Stein Kaasa
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom
| | - Pål Klepstad
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom
| | - Donald C McMillan
- Barry J.A. Laird, Marianne J. Hjermstad, Stein Kaasa, and Pål Klepstad, Norwegian University of Science and Technology; Pål Klepstad, Trondheim University Hospital, Trondheim; Marianne J. Hjermstad and Stein Kaasa, Oslo University Hospital, Oslo, Norway; Barry J.A. Laird, Marie Fallon, and Sharon Tuck, University of Edinburgh, Edinburgh; and Donald C. McMillan, University of Glasgow, Glasgow, United Kingdom
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Løhre ET, Klepstad P, Bennett MI, Brunelli C, Caraceni A, Fainsinger RL, Knudsen AK, Mercadante S, Sjøgren P, Kaasa S. From "Breakthrough" to "Episodic" Cancer Pain? A European Association for Palliative Care Research Network Expert Delphi Survey Toward a Common Terminology and Classification of Transient Cancer Pain Exacerbations. J Pain Symptom Manage 2016; 51:1013-9. [PMID: 26921493 DOI: 10.1016/j.jpainsymman.2015.12.329] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/05/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Cancer pain can appear with spikes of higher intensity. Breakthrough cancer pain (BTCP) is the most common term for the transient exacerbations of pain, but the ability of the nomenclature to capture relevant pain variations and give treatment guidance is questionable. OBJECTIVES To reach consensus on definitions, terminology, and subclassification of transient cancer pain exacerbations. METHODS The most frequent authors on BTCP literature were identified using the same search strategy as in a systematic review and invited to participate in a two-round Delphi survey. Topics with a low degree of consensus on BTCP classification were refined into 20 statements. The participants rated their degree of agreement with the statements on a numeric rating scale (0-10). Consensus was defined as a median numeric rating scale score of ≥7 and an interquartile range of ≤3. RESULTS Fifty-two authors had published three or more articles on BTCP over the past 10 years. Twenty-seven responded in the first round and 24 in the second round. Consensus was reached for 13 of 20 statements. Transient cancer pain exacerbations can occur without background pain, when background pain is uncontrolled, and regardless of opioid treatment. There exist cancer pain exacerbations other than BTCP, and the phenomenon could be named "episodic pain." Patient-reported treatment satisfaction is important with respect to assessment. Subclassification according to pain pathophysiology can provide treatment guidance. CONCLUSION Significant transient cancer pain exacerbations include more than just BTCP. Patient input and pain classification are important factors for tailoring treatment.
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Affiliation(s)
- Erik Torbjørn Løhre
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Cinzia Brunelli
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Augusto Caraceni
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Robin L Fainsinger
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Anne Kari Knudsen
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Seternes A, Fasting S, Klepstad P, Mo S, Dahl T, Björck M, Wibe A. Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient. Crit Care 2016; 20:164. [PMID: 27233244 PMCID: PMC4884359 DOI: 10.1186/s13054-016-1337-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 05/12/2016] [Indexed: 02/03/2023]
Abstract
Background Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs. Methods All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients’ records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs. Results A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4–66.4) minutes and in the OR 98.2 (94.6–101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844). Conclusions VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.
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Affiliation(s)
- Arne Seternes
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway. .,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway.
| | - Sigurd Fasting
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
| | - Skule Mo
- Department of Anesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway
| | - Torbjørn Dahl
- Department of Vascular Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Arne Wibe
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Prinsesse Kristinas gate 3, 7030, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Høgskoleringen 1, 7491, Trondheim, Norway
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Haugdahl HS, Storli SL, Meland B, Dybwik K, Romild U, Klepstad P. Underestimation of Patient Breathlessness by Nurses and Physicians during a Spontaneous Breathing Trial. Am J Respir Crit Care Med 2016; 192:1440-8. [PMID: 26669474 DOI: 10.1164/rccm.201503-0419oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
RATIONALE Breathlessness is a prevalent and distressing symptom in intensive care unit patients. There is little evidence of the ability of healthcare workers to assess the patient's experiences of breathing. Patient perception of breathing is essential in symptom management, and patient perception during a spontaneous breathing trial (SBT) might be related to extubation success. OBJECTIVES To assess mechanically ventilated patients' experiences of breathlessness during SBT. METHODS This was a prospective observational multicenter study of 100 mechanically ventilated patients. We assessed the agreement between nurses, physicians, and patients' 11-point Numerical Rating Scales scores of breathlessness, perception of feeling secure, and improvement of respiratory function at the end of an SBT (most performed with some level of support). We also determined the association between breathlessness and demographic factors or respiratory observations. MEASUREMENTS AND MAIN RESULTS Sixty-two patients (62%) reported moderate or severe breathlessness (Numerical Rating Scales ≥ 4). The median intensity of breathlessness reported by patients was five compared with two by nurses and physicians (P < 0.001). Patients felt less secure and reported less improvement of respiratory function compared with nurses' and physicians' ratings. About half of the nurses and physicians underestimated breathlessness (difference score, ≤-2) compared with the patients' self-reports. Underestimation of breathlessness was not associated with professional competencies. There were no major differences in objective assessments of respiratory function in patients with moderate or severe breathlessness, and no apparent relationship between breathlessness during the SBT and extubation outcome. CONCLUSIONS Patients reported higher breathlessness after SBT compared with nurses and physicians. Clinical trial registered with www.clinicaltrials.gov (NCT 01928277).
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Affiliation(s)
- Hege S Haugdahl
- 1 Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.,2 Department for Research, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway.,3 Nord Trøndelag University College, Levanger, Norway
| | - Sissel L Storli
- 1 Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Barbro Meland
- 4 Department of Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Knut Dybwik
- 5 Department of Anesthesiology, Nordland Hospital, Bodø, Norway.,6 Faculty of Professional Studies, University of Nordland, Bodø, Norway
| | - Ulla Romild
- 2 Department for Research, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway.,7 Public Health Agency of Sweden, Östersund, Sweden; and
| | - Pål Klepstad
- 4 Department of Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway.,8 Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Alawneh A, Tuqan W, Innabi A, Al-Nimer Y, Azzouqah O, Rimawi D, Taqash A, Elkhatib M, Klepstad P. Clinical Factors Associated With a Short Survival Time After Percutaneous Nephrostomy for Ureteric Obstruction in Cancer Patients: An Updated Model. J Pain Symptom Manage 2016; 51:255-61. [PMID: 26497918 DOI: 10.1016/j.jpainsymman.2015.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/25/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
CONTEXT Patients with advanced cancer can develop ureteric obstruction. Percutaneous nephrostomy (PCN) tube insertion can relieve this obstruction and prevent renal failure. PCN is associated with complications and can worsen quality of life. Prognostic models of survival after PCN in cancer patients can help identify the patients who will most likely benefit from this intervention. This work updates a prognostic model to predict overall survival in cancer patients after receiving PCN. OBJECTIVES The primary objective was to assess survival of patients with malignant urinary obstruction after PCN tube insertion. The secondary objective was to identify factors associated with poor prognosis in this group of patients and externally validate an existing model. METHODS We conducted a retrospective analysis of 211 patients who had malignant urinary obstruction and received PCN tube insertion. RESULTS The median survival was 5.05 months (95% CI = 3.87-7.11; range 2-963 days). On univariate analysis, the factors significantly associated with shorter survival were type of malignancy, bilateral hydronephrosis, serum albumin <3.5 mg/dL, presence of metastasis, ascites, and pleural effusion (P < 0.05). Multivariate analysis using a Cox proportional hazards regression model showed that type of malignancy, serum albumin <3.5 mg/dL, pleural effusion, and bilateral hydronephrosis were significantly associated with shorter survival (P < 0.05). Using the latter three factors, we stratified patients into four prognostic groups: zero risk factors (32 patients), one risk factor (85 patients), two risk factors (78 patients), and three risk factors (16 patients). Median survival for each group was 17.6 months, 7.7 months, 2.2 months, and 1.7 months, respectively (P < 0.0001). CONCLUSION Survival in patients with malignant ureteric obstruction can range widely from a few days to a few years. The presented prognostic model is an updated model and can be used to identify patients with poor survival after PCN.
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Affiliation(s)
| | | | | | | | - Ola Azzouqah
- University of New Mexico, Albuquerque, New Mexico, USA
| | | | | | | | - Pål Klepstad
- St. Olavs University Hospital, Trondheim, Norway
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Klepstad P, Skorpen F. Genetic variability of pain - A patient focused end-point. Scand J Pain 2016; 10:13-14. [PMID: 28361764 DOI: 10.1016/j.sjpain.2015.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- St. Olavs Hospital, Department of Anaesthesiology and Intensive Care Medicine, Trondheim, Norway
| | - Frank Skorpen
- Department of Laboratory Medicine, Children's and Women's Health, Faculty of Medicine, Norwegian University of Science and Technology (NTNU),Trondheim, Norway
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Alawneh A, Yasin H, Khirfan G, Qayas BA, Ammar K, Rimawi D, Klepstad P. Psychometric properties of the Arabic version of EORTC QLQ-C15-PAL among cancer patients in Jordan. Support Care Cancer 2015; 24:2455-62. [PMID: 26660151 DOI: 10.1007/s00520-015-3018-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 11/08/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Health related quality of life (HRQOL) is an important outcome in cancer care and needs assessment by a valid questionnaire. HRQOL questionnaires need to be validated after translations to other languages and cultural settings. The purpose of this study is to evaluate the psychometric properties of the Arabic version of the European Organization for Research and Treatment of Cancer Quality of Life 15 items Questionnaire for Palliative Care (EORTC QLQ-C15-PAL). METHODS This is a cross-sectional study of a convenient sample of inpatients with cancer. RESULTS One hundred seventy-five patients completed the EORTC QLQ-C15-PAL questionnaire. Cronbach's alpha coefficient met the 0.7 alpha criterion. Confirmatory factor analysis met the goodness of fit criteria; goodness-of-fit index (GFI), comparative fit index (CFI), normed fit index (NFI) and non-normed fit index (NNFI) >0.90 and root mean square error of approximation (RMSEA) <0.06. All item-scale correlation coefficients exceeded the set value of 0.40, indicating satisfactory convergent validity. In terms of discriminant validity, all items in the questionnaire showed a higher item-scale correlation than item-other scale correlation, except for items 1 and 2 (physical function scale) that showed a higher correlation with fatigue. Construct validity was tested by item inter scale correlation coefficient. All constructs had correlation coefficient <0.70. External validity was tested by comparison of scores of patients who had metastasis and who did not have metastasis. Significant differences (P value <0.05) were found in all scales except for nausea. Age groups were compared and showed significant differences for physical function, fatigue, and global score of HRQOL. CONCLUSION The Arabic version of the EORTC QLQ-C15-PAL is valid and reliable.
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Affiliation(s)
- Alia Alawneh
- Palliative Medicine Department, King Hussein Cancer Center, Queen Rania street, Amman, Jordan.
| | - Hesham Yasin
- Internal Medicine Department, King Hussein Cancer Center, Amman, Jordan
| | - Ghaleb Khirfan
- Internal Medicine Department, King Hussein Cancer Center, Amman, Jordan
| | - Bashar Abu Qayas
- Internal Medicine Department, King Hussein Cancer Center, Amman, Jordan
| | - Khawla Ammar
- Office of Scientific affairs, King Hussein Cancer Center, Amman, Jordan
| | - Dalia Rimawi
- Office of Scientific affairs, King Hussein Cancer Center, Amman, Jordan
| | - Pål Klepstad
- Department of Intensive Care Medicine, St. Olav's University Hospital, 7006, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology; European Palliative Care Research Center, Trondheim, Norway
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Stuedahl M, Vold S, Klepstad P, Stafseth SK. Interrater reliability of Nursing Activities Score among Intensive Care Unit health professionals. Rev Esc Enferm USP 2015; 49 Spec No:117-22. [PMID: 26761701 DOI: 10.1590/s0080-623420150000700017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/21/2015] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze the interrater reliability of NAS among critical care nurses and managers in an ICU. Method This was a methodological study performed in an adult, general ICU in Norway. In a random selection of patients, the NAS was scored on 101 patients by three raters: a critical care nurse, an ICU physician and a nurse manager. Interrater reliability was analyzed by agreement between groups and kappa statistics. Results The mean NAS were 88.4 (SD=16.2) and 88.7 (SD=24.5) respectively for the critical care nurses and nurse managers. A lower mean of 83.7 (SD=21.1) was found for physicians. The 18 medical interventions showed higher agreement between critical care nurses and physicians (85.6%), than between critical care nurses and nurse managers (78.7). In the five nursing activities the Kappa-coefficients were low for all activities in all compared groups. Conclusion The study indicated a satisfactory agreement of nursing workload between critical care nurses and managers.
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Affiliation(s)
- Marit Stuedahl
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Sidsel Vold
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway
| | - Siv Karlsson Stafseth
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Lee YJ, Suh SY, Song J, Lee SS, Seo AR, Ahn HY, Lee MA, Kim CM, Klepstad P. Serum and urine concentrations of morphine and morphine metabolites in patients with advanced cancer receiving continuous intravenous morphine: an observational study. BMC Palliat Care 2015; 14:53. [PMID: 26507979 PMCID: PMC4624671 DOI: 10.1186/s12904-015-0052-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 10/22/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The feasibility and clinical implication of drug monitoring of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) need further investigation. This study aimed to determine what predicts serum concentrations of morphine in cancer patients receiving continuously intravenous morphine, the relationships between serum concentration of morphine/its metabolites and urinary concentrations, and the relation between morphine concentrations and with clinical outcomes. METHODS We collected serum and urine samples from 24 patients with advanced cancer undergoing continuously intravenous morphine therapy. Serum samples were obtained at day one. Spot urine samples were collected once daily on three consecutive days. Pain and adverse drug events were assessed using the Korean version of MD Anderson Symptom Inventory. RESULTS A total of 96 samples (72 urine and 24 serum samples) were collected. Median dose of morphine was 82.0 mg/24 h. In a multivariate analysis, total daily morphine dose was the most significant predictors of both serum and urine concentration of morphine. Morphine, M6G, and M3G in serum and urine were statistical significantly correlated (correlation coefficient = 0.81, 0.44, 0.56; p values < 0.01, 0.03, 0.01, respectively). CONCLUSION Spot urine concentrations of morphine and its metabolites were highly correlated to those of serum. Total dose of daily morphine was related to both serum and urine concentration of morphine and its metabolites.
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Affiliation(s)
- Yong Joo Lee
- Department of Palliative Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University School of Medicine, 30 Pildong-ro 1-gil, Jung-gu, Seoul, 100-715, South Korea.
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| | | | - Ah-Ram Seo
- Department of Statistics, Dongguk University, Seoul, South Korea.
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University, Seoul, South Korea.
| | - Myung Ah Lee
- Division of Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Chul-Min Kim
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Pål Klepstad
- Departments of Anaesthesiology and Intensive Care Medicine, St. Olvas University Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Medical Faculty, Norwegian University of Technology and Science, Trondheim, Norway.
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Haugdahl HS, Storli SL, Meland B, Dybwik K, Romild U, Klepstad P. Assessments of patients' Experiences of breathlessness during a spontaneous breathing trial. Intensive Care Med Exp 2015. [PMCID: PMC4797886 DOI: 10.1186/2197-425x-3-s1-a101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Kurita GP, Benthien KS, Nordly M, Mercadante S, Klepstad P, Sjøgren P. The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review. Acta Anaesthesiol Scand 2015; 59:1103-15. [PMID: 25684104 DOI: 10.1111/aas.12485] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 01/12/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The present systematic review analysed the existing evidence of analgesic efficacy and side effects of opioids without and with adjuvant analgesics delivered by neuraxial route (epidural and subarachnoid) in adult patients with cancer. METHODS Search strategy was elaborated with words related to cancer, pain, neuraxial route, analgesic and side effects. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. Studies were analysed according to methods, results, quality of evidence, and strength of recommendation. RESULTS The number of abstracts retrieved was 2147, and 84 articles were selected for full reading. The final selection comprised nine articles regarding randomised controlled trials (RCTs) divided in four groups: neuraxial combinations of opioid and adjuvant analgesic compared with neuraxial administration of opioid alone (n = 4); single neuraxial drug in bolus compared with continuous administration (n = 2); single neuraxial drug compared with neuraxial placebo (n = 1); and neuraxial opioid combined with or without adjuvant analgesic compared with other comprehensive medical management than neuraxial analgesics (n = 2). The RCTs presented clinical and methodological diversity that precluded a meta-analysis. They also presented several limitations, which reduced study internal validity. However, they demonstrated better pain control for all interventions analysed. Side effects were described, but there were few significant differences in favour of the tested interventions. CONCLUSION Heterogeneous characteristics and several methodological limitations of the studies resulted in evidence of low quality and a weak recommendation for neuraxial administration of opioids with or without adjuvant analgesics in adult patients with cancer.
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Affiliation(s)
- G. P. Kurita
- Section of Palliative Medicine; Department of Oncology; Multidisciplinary Pain Centre; Department of Neuroanaesthesiology; Rigshospitalet - Copenhagen University Hospital; Copenhagen Denmark
| | - K. S. Benthien
- Department of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; København Denmark
- Department of Oncology; Rigshospitalet - Copenhagen University Hospital; Copenhagen Denmark
| | - M. Nordly
- Department of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; København Denmark
- Department of Oncology; Rigshospitalet - Copenhagen University Hospital; Copenhagen Denmark
| | - S. Mercadante
- Anesthesia and Intensive Care Unit; Pain Relief and Palliative Care Unit; La Maddalena Cancer Center; Palermo Italy
- Department of Anesthesia, Intensive Care & Emergencies; University of Palermo; Palermo Italy
| | - P. Klepstad
- Department of Intensive Care Medicine; St. Olavs University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology; Trondheim Norway
| | - P. Sjøgren
- Department of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; København Denmark
- Department of Oncology; Rigshospitalet - Copenhagen University Hospital; Copenhagen Denmark
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Kotlinska-Lemieszek A, Klepstad P, Haugen DF. Clinically significant drug-drug interactions involving opioid analgesics used for pain treatment in patients with cancer: a systematic review. Drug Des Devel Ther 2015; 9:5255-67. [PMID: 26396499 PMCID: PMC4577251 DOI: 10.2147/dddt.s86983] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Opioids are the most frequently used drugs to treat pain in cancer patients. In some patients, however, opioids can cause adverse effects and drug-drug interactions. No advice concerning the combination of opioids and other drugs is given in the current European guidelines. OBJECTIVE To identify studies that report clinically significant drug-drug interactions involving opioids used for pain treatment in adult cancer patients. DESIGN AND DATA SOURCES Systematic review with searches in Embase, MEDLINE, and Cochrane Central Register of Controlled Trials from the start of the databases (Embase from 1980) through January 2014. In addition, reference lists of relevant full-text papers were hand-searched. RESULTS Of 901 retrieved papers, 112 were considered as potentially eligible. After full-text reading, 17 were included in the final analysis, together with 15 papers identified through hand-searching of reference lists. All of the 32 included publications were case reports or case series. Clinical manifestations of drug-drug interactions involving opioids were grouped as follows: 1) sedation and respiratory depression, 2) other central nervous system symptoms, 3) impairment of pain control and/or opioid withdrawal, and 4) other symptoms. The most common mechanisms eliciting drug-drug interactions were alteration of opioid metabolism by inhibiting the activity of cytochrome P450 3A4 and pharmacodynamic interactions due to the combined effect on opioid, dopaminergic, cholinergic, and serotonergic activity in the central nervous system. CONCLUSION Evidence for drug-drug interactions associated with opioids used for pain treatment in cancer patients is very limited. Still, the cases identified in this systematic review give some important suggestions for clinical practice. Physicians prescribing opioids should recognize the risk of drug-drug interactions and if possible avoid polypharmacy.
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Affiliation(s)
- Aleksandra Kotlinska-Lemieszek
- Palliative Medicine Chair and Department, University Hospital of the Lord’s Transfiguration, Karol Marcinkowski University of Medical Sciences, Poznan, Poland
| | - Pål Klepstad
- European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Anaesthesiology and Intensive Care Medicine, St Olavs Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dagny Faksvåg Haugen
- European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Regional Centre of Excellence for Palliative Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
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Mercadante S, Klepstad P, Kurita GP, Sjøgren P, Pigni A, Caraceni A. Minimally invasive procedures for the management of vertebral bone pain due to cancer: The EAPC recommendations. Acta Oncol 2015; 55:129-33. [PMID: 26371516 DOI: 10.3109/0284186x.2015.1073351] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Image-guided percutaneous ablation methods have proved effective for treatment of benign bone tumors and for palliation of metastases involving the bone. However, the role of these techniques is controversial and has to be better defined in the setting of palliative care. METHODS A systematic review of the existing data regarding minimally invasive techniques for the pain management of vertebral bone metastases was performed by experts of the European Palliative Care Research Network. RESULTS Only five papers were taken into consideration after performing rigorous screening according to inclusion and exclusion criteria (low number of patients, retrospective series, proceedings). DISCUSSION According to the present data a recommendation should be made to perform kiphoplasty in patients with vertebral tumors or metastases. However, the strength of this recommendation was based on one randomized controlled study. Several weaknesses and low quality of study design were observed with other techniques. CONCLUSION Further randomized controlled trials are required to improve the strength of evidence available to suggest these procedures on large scale. Until then, the balance of evidence favors the use of these procedures in a small select cohort of patients with severe and disabling back pain refractory to medical therapy.
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Affiliation(s)
- Sebastiano Mercadante
- a Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit , La Maddalena Cancer Center , Palermo , Italy
| | - Pål Klepstad
- b Department of Intensive Care Medicine , St. Olavs University Hospital , Trondheim , Norway
- c Department of Circulation and Medical Imaging , Norwegian University of Science and Technology , Trondheim , Norway
| | - Geana Paula Kurita
- d Section of Palliative Medicine, Department of Oncology , Rigshospitalet, Copenhagen University Hospital , Denmark
- e Multidisciplinary Pain Centre, Department Neuroanaesthesiology , Rigshospitalet, Copenhagen University Hospital , Denmark
| | - Per Sjøgren
- d Section of Palliative Medicine, Department of Oncology , Rigshospitalet, Copenhagen University Hospital , Denmark
- f Department of Clinical Medicine , Faculty of Health and Medical Sciences, University of Copenhagen , Denmark and
| | - Alessandra Pigni
- g Palliative Care, Pain Therapy and Rehabilitation Department , Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy on behalf of the European Palliative Care Research Collaborative (EPCRC)
| | - Augusto Caraceni
- g Palliative Care, Pain Therapy and Rehabilitation Department , Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy on behalf of the European Palliative Care Research Collaborative (EPCRC)
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Kurita GP, Lundström S, Sjøgren P, Ekholm O, Christrup L, Davies A, Kaasa S, Klepstad P, Dale O. Renal function and symptoms/adverse effects in opioid-treated patients with cancer. Acta Anaesthesiol Scand 2015; 59:1049-59. [PMID: 25943005 DOI: 10.1111/aas.12521] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 06/19/2014] [Accepted: 03/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Renal impairment and the risk of toxicity caused by accumulation of opioids and/or active metabolites is an under-investigated issue. This study aimed at analysing if symptoms/adverse effects in opioid-treated patients with cancer were associated with renal function. METHODS Cross-sectional multicentre study (European Pharmacogenetic Opioid Study, 2005-2008), in which 1147 adult patients treated exclusively with only one of the most frequently reported opioids (morphine/oxycodone/fentanyl) for at least 3 days were analysed. Fatigue, nausea/vomiting, pain, loss of appetite, constipation and cognitive dysfunction were assessed (EORTC QLQ-C30). Glomerular filtration rate (GFR) was estimated using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI Creatinine) equations. RESULTS Mild to severe low GFR was observed among 40-54% of patients. CG equation showed that patients with mild and moderate/severe low GFR on morphine treatment had higher odds of having severe constipation (P < 0.01) than patients with normal GFR. In addition, patients with moderate/severe low GFR on morphine treatment were more likely to have loss of appetite (P = 0.04). No other significant associations were found. CONCLUSION Only severe constipation and loss of appetite were associated with low GFR in patients treated with morphine. Oxycodone and fentanyl, in relation to the symptoms studied, seem to be safe as used and titrated in routine cancer pain care.
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Affiliation(s)
- G. P. Kurita
- Department of Oncology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
- Multidisciplinary Pain Centre; Department of Neuroanaesthesiology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
| | - S. Lundström
- Stockholms Sjukhem Foundation and Department of Oncology Pathology; Karolinska Institute; Stockholm Sweden
| | - P. Sjøgren
- Department of Oncology; Rigshospitalet Copenhagen University Hospital; Copenhagen Denmark
- Department of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - O. Ekholm
- National Institute of Public Health; University of Southern Denmark; Copenhagen Denmark
| | - L. Christrup
- Department of Drug Design and Pharmacology; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - A. Davies
- Royal Surrey County Hospital; Guildford UK
| | - S. Kaasa
- Department of Oncology; Trondheim University Hospital; St. Olav Hospital; Trondheim Norway
- European Palliative Care Research Centre; DMF; Norwegian University of Science and Technology; Trondheim Norway
| | - P. Klepstad
- Department of Intensive Care Medicine; St Olavs University Hospital; Trondheim Norway
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology; Trondheim Norway
| | - O. Dale
- Department of Circulation and Medical Imaging; Norwegian University of Science and Technology; Trondheim Norway
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Mercadante S, Klepstad P, Kurita GP, Sjøgren P, Giarratano A. Sympathetic blocks for visceral cancer pain management: A systematic review and EAPC recommendations. Crit Rev Oncol Hematol 2015; 96:577-83. [PMID: 26297518 DOI: 10.1016/j.critrevonc.2015.07.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 05/27/2015] [Accepted: 07/28/2015] [Indexed: 01/28/2023] Open
Abstract
The neurolytic blocks of sympathetic pathways, including celiac plexus block (CPB) and superior hypogastric plexus block (SHPB) , have been used for years. The aim of this review was to assess the evidence to support the performance of sympathetic blocks in cancer patients with abdominal visceral pain. Only comparison studies were included. All data from the eligible trials were analyzed using the GRADE system. Twenty-seven controlled studies were considered. CPB, regardless of the technique used, improved analgesia and/or decrease opioid consumption, and decreased opioid-induced adverse effects in comparison with a conventional analgesic treatment. In one study patients treated with superior hypogastric plexus block (SHPB) had a decrease in pain intensity and a less morphine consumption, while no statistical differences in adverse effects were found. The quality of these studies was generally poor due to several limitations, including sample size calculation, allocation concealment, no intention to treat analysis. However, at least two CPB studies were of good quality. Data regarding the comparison of techniques or other issues were sparse and of poor quality, and evidence could not be analysed. On the basis of existing evidence, CPB has a strong recommendation in patients with pancreatic cancer pain. There is a weak recommendation for SHPB, that should be based on individual conditions. Data regarding the choice of the technique are sparse and unfit to provide any recommendation.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy; Department Anesthesia, Intensive Care & Emergencies, University of Palermo, Italy.
| | - Pål Klepstad
- Department Intensive Care Medicine, St. Olavs University Hospital, Trondheim, Norway; Department Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Geana Paula Kurita
- Section of Palliative Medicine, Department Oncology, Rigshospitalet-Copenhagen University Hospital, Denmark; Multidisciplinary Pain Centre, Department Neuroanaesthesiology, Rigshospitalet-Copenhagen University Hospital, Denmark.
| | - Per Sjøgren
- Department Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Section of Palliative Medicine, Department Oncology, Rigshospitalet-Copenhagen University Hospital, Denmark.
| | - Antonino Giarratano
- Chair of Anesthesiology, Intensive care and pain therapy, University of Palermo, Italy.
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Klepstad P, Kurita GP, Mercadante S, Sjøgren P. Evidence of peripheral nerve blocks for cancer-related pain: a systematic review. Minerva Anestesiol 2015; 81:789-793. [PMID: 25384692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The European Association for Palliative Care has initiated a comprehensive program to achieve an over-all review of the evidence of multiple cancer pain management strategies in order to extend the current guideline for treatment of cancer pain. The present systematic review analyzed the existing evidence of analgesic efficacy for peripheral nerve blocks in adult patients with cancer. A search strategy was elaborated with words related to cancer, pain, peripheral nerve and block. The search was performed in PubMed, EMBASE, and Cochrane for the period until February 2014. The number of abstracts retrieved was 155. No controlled studies were identified. Sixteen papers presented a total of 79 cases. The blocks applied were paravertebral blocks (10 cases), blocks in the head region (2 cases), plexus blocks (13 cases), intercostal blocks (43 cases) and others (11 cases). In general, most cases reported good pain relief and no side effects. The use of peripheral blocks is based upon anecdotal evidence. However, this review only demonstrates the lack of studies, which does not equal a lack of effectiveness.
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Affiliation(s)
- P Klepstad
- Department of Intensive Care Medicine, St. Olavs University Hospital, Trondheim, Norway -
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Andersen FH, Flaatten H, Klepstad P, Romild U, Kvåle R. Long-term survival and quality of life after intensive care for patients 80 years of age or older. Ann Intensive Care 2015; 5:53. [PMID: 26055187 PMCID: PMC4456598 DOI: 10.1186/s13613-015-0053-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/19/2015] [Indexed: 01/20/2023] Open
Abstract
Background Comparison of survival and quality of life in a mixed ICU population of patients 80 years of age or older with a matched segment of the general population. Methods We retrospectively analyzed survival of ICU patients ≥80 years admitted to the Haukeland University Hospital in 2000–2012. We prospectively used the EuroQol-5D to compare the health-related quality of life (HRQOL) between survivors at follow-up and an age- and gender-matched general population. Follow-up was 1–13.8 years. Results The included 395 patients (mean age 83.8 years, 61.0 % males) showed an overall survival of 75.9 (ICU), 59.5 (hospital), and 42.0 % 1 year after the ICU. High ICU mortality was predicted by age, mechanical ventilator support, SAPS II, maximum SOFA, and multitrauma with head injury. High hospital mortality was predicted by an unplanned surgical admission. One-year mortality was predicted by respiratory failure and isolated head injury. We found no differences in HRQOL at follow-up between survivors (n = 58) and control subjects (n = 179) or between admission categories. Of the ICU non-survivors, 63.2 % died within 2 days after ICU admission (n = 60), and 68.3 % of these had life-sustaining treatment (LST) limitations. LST limitations were applied for 71.3 % (n = 114) of the hospital non-survivors (ICU 70.5 % (n = 67); post-ICU 72.3 % (n = 47)). Conclusions Overall 1-year survival was 42.0 %. Survival rates beyond that were comparable to those of the general octogenarian population. Among survivors at follow-up, HRQOL was comparable to that of the age- and sex-matched general population. Patients admitted for planned surgery had better short- and long-term survival rates than those admitted for medical reasons or unplanned surgery for 3 years after ICU admittance. The majority of the ICU non-survivors died within 2 days, and most of these had LST limitation decisions. Electronic supplementary material The online version of this article (doi:10.1186/s13613-015-0053-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Finn H Andersen
- Department of Anesthesia and Intensive Care, Møre and Romsdal Health Trust, Ålesund Hospital, 6026, Ålesund, Norway,
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Betten J, Roness AK, Endreseth BH, Trønnes H, Tyvold SS, Klepstad P, Nordseth T. Assessment of the time-dependent need for stay in a high dependency unit (HDU) after major surgery by using data from an anesthesia information management system. J Clin Monit Comput 2015; 30:235-41. [PMID: 26013979 DOI: 10.1007/s10877-015-9707-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
Admittance to a high dependency unit (HDU) is expensive. Patients who receive surgical treatment with 'low anterior resection of the rectum' (LAR) or 'abdominoperineal resection of the rectum' (APR) at our hospital are routinely treated in an HDU the first 16-24 h of the postoperative (PO) period. The aim of this study was to describe the extent of HDU-specific interventions given. We included patients treated with LAR or APR at the St. Olav University Hospital (Trondheim, Norway) over a 1-year period. Physiologic data and HDU-interventions recorded during the PO-period were obtained from the anesthesia information management system (AIMS). HDU-specific interventions were defined as the need for respiratory support, fluid replacement therapy >500 ml/h, vasoactive medications, or a need for high dose opioids (morphine >7.5 mg/h i.v.). Sixty-two patients were included. Most patients needed HDU-specific interventions during the first 6 h of the PO period. After this, one-third of the patients needed one or more of the HDU-specific interventions for shorter periods of time. Another one-third of the patients had a need for HDU-specific therapies for more than ten consecutive hours, primarily an infusion of nor-epinephrine. Most patients treated with LAR or APR was in need of an HDU-specific intervention during the first 6 h of the PO-period, with a marked decline after this time period. The applied methodology, using an AIMS, demonstrates that there is great variability in individual patients' postoperative needs after major surgery, and that these needs are dynamic in their nature.
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Affiliation(s)
- Jan Betten
- Faculty of Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | | | - Birger Henning Endreseth
- Department of Surgery, St. Olav Hospital, 7006, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Håkon Trønnes
- Department of Anesthesia and Intensive Care Medicine, St. Olav Hospital, 7006, Trondheim, Norway
| | - Stig Sverre Tyvold
- Department of Anesthesia and Intensive Care Medicine, St. Olav Hospital, 7006, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesia and Intensive Care Medicine, St. Olav Hospital, 7006, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, 7491, Trondheim, Norway
| | - Trond Nordseth
- Department of Anesthesia and Intensive Care Medicine, St. Olav Hospital, 7006, Trondheim, Norway. .,Regional Center for Health Care Research, St. Olav Hospital, 7006, Trondheim, Norway.
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Paulsen Ø, Aass N, Klepstad P, Kaasa S. Reply to A. Molfino et al. J Clin Oncol 2015; 33:1513. [DOI: 10.1200/jco.2014.60.6475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ørnulf Paulsen
- Telemark Hospital Trust, Skien; Norwegian University of Science and Technology, Trondheim, Norway
| | - Nina Aass
- Oslo University Hospital; University of Oslo, Oslo, Norway
| | - Pål Klepstad
- St Olavs Hospital, Trondheim University Hospital; Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- Norwegian University of Science and Technology; St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Holli Halset J, Hanssen SW, Espinosa A, Klepstad P. Tromboelastography: variability and relation to conventional coagulation test in non-bleeding intensive care unit patients. BMC Anesthesiol 2015; 15:28. [PMID: 25755628 PMCID: PMC4353683 DOI: 10.1186/s12871-015-0011-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 02/21/2015] [Indexed: 01/23/2023] Open
Abstract
Background Intensive care unit (ICU) patients usually have abnormal biochemical and hematological laboratory test results as a consequence of organ dysfunction and underlying disease. Thromboelastography (TEG®) is a point-of-care laboratory analysis that gives an overview of several aspects of the coagulation process. In order to be able to perform a clinical interpretation of abnormal TEG® results the expected values from non-bleeding ICU patients should be known. The aim of this study is to report the normal variability observed in non-bleeding, non-transfused ICU patients. Methods Adult ICU patients without bleeding in the last 24 hours, who had not received blood products within the last 24 hours, with no hematological diseases and no anticoagulation therapeutic treatment were included. Standard clinical chemistry tests, coagulation tests and TEG® were obtained. All results were reported in relation to standard reference values. TEG® values were compared with routine coagulation measurement using Spearman correlations. Results We observed that the normal variability observed in non-bleeding, non-transfused ICU patients in this study included abnormally high TEG® values for maximum amplitude (MA) (73%). None of the patients showed MA results corresponding to hypocoagulability. Other coagulation tests were also changed with elevated D-Dimer, fibrinogen and APTT values, and a low ATIII value. Conclusion In unselected ICU patients without bleeding or known factors that influence coagulation, a TEG® value of MA is often elevated suggesting hypercoagulability. This finding should be considered when interpreting TEG® observations obtained in ICU patients.
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Affiliation(s)
- Jørgen Holli Halset
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Simon Wøhlert Hanssen
- Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Aurora Espinosa
- Department of Immunology and Transfusion Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olav University Hospital, Trondheim, Norway ; Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway ; Department of Intensive Care Medicine, St. Olav University Hospital, P.O. box 3250 Sluppen, N-7006 Trondheim, Norway
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Kotlinska-Lemieszek A, Paulsen O, Kaasa S, Klepstad P. Polypharmacy in patients with advanced cancer and pain: a European cross-sectional study of 2282 patients. J Pain Symptom Manage 2014; 48:1145-59. [PMID: 24780183 DOI: 10.1016/j.jpainsymman.2014.03.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 02/24/2014] [Accepted: 04/02/2014] [Indexed: 11/17/2022]
Abstract
CONTEXT Patients with advanced cancer need multiple drugs to control symptoms and to treat cancer and concomitant diseases. At the same time, the goal of treatment changes as life expectancy becomes limited. This results in a risk for polypharmacy, maintained use of unneeded drugs, and drug-drug interactions (DDIs). OBJECTIVES The aim of the study was to analyze the use of medications and to identify unneeded drugs, and drugs and drug combinations with a risk for DDIs in a cohort of advanced cancer pain patients, defined by a need for a World Health Organization analgesic ladder Step III opioid. METHODS All drugs taken within a study day by cancer patients receiving opioids for moderate or severe pain (Step III opioids) were analyzed. Nonopioids and adjuvants were analyzed for their use across countries. Unneeded medications and drugs and drug combinations with a risk for pharmacodynamic and pharmacokinetic DDIs were identified on the basis of published literature and electronic resources. RESULTS In total, 2282 patients from 17 centers in 11 European countries were included. They received a mean of 7.8 drugs (range 1-20). Over one-quarter used 10 or more medications. The drugs and drug classes most frequently coadministered with opioids were proton pump inhibitors, laxatives, corticosteroids, paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, metoclopramide, benzodiazepines, anticoagulants, antibiotics, anticonvulsants, diuretics, and antidepressants. The use of nonopioids and essential adjuvants varied across countries. Approximately 45% of patients received unnecessary or potentially unnecessary drugs, and about 7% were given duplicate or antagonizing agents. Exposures to DDIs were frequent and increased the risk of sedation, gastric ulcerations, bleedings, and neuropsychiatric and cardiac complications. Many patients were exposed to pharmacokinetic DDIs involving cytochrome P450, including about 58% who used a Step III opioid CYP3A4 (izoenzyme of cytochrome P450) substrate, and more than 10% who were given major CYP3A4 inhibitors or inducers. CONCLUSION Patients with cancer treated with a World Health Organization Step III opioid use a high number of drugs. Nonopioid analgesics and corticosteroids are frequently used, but different patterns of use between countries were found. Many patients receive unneeded drugs and are at risk of serious DDIs. These findings demonstrate that drug therapy in these patients needs to be evaluated continuously.
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Affiliation(s)
- Aleksandra Kotlinska-Lemieszek
- Department of Palliative Medicine Karol Marcinkowski University of Medical Sciences, Poznan, Poland; Hospice Palium, University Hospital of the Lord's Transfiguration, Poznan, Poland.
| | - Ornulf Paulsen
- Palliative Care Unit, Department of Medicine, Telemark Hospital Trust, Skien, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Anaesthesiology and Intensive Care Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Uleberg O, Vinjevoll OP, Kristiansen T, Klepstad P. Norwegian trauma care: a national cross-sectional survey of all hospitals involved in the management of major trauma patients. Scand J Trauma Resusc Emerg Med 2014; 22:64. [PMID: 25388400 PMCID: PMC4237744 DOI: 10.1186/s13049-014-0064-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Approximately 10% of the Norwegian population is injured every year, with injuries ranging from minor injuries treated by general practitioners to major and complex injuries requiring specialist in-hospital care. There is a lack of knowledge concerning the caseload of potentially severely injured patients in Norwegian hospitals. Aim of the study was to describe the current status of the Norwegian trauma system by identifying the number and the distribution of contributing hospitals and the caseload of potentially severely injured trauma patients within these hospitals. METHODS A cross-sectional survey with a structured questionnaire was sent in the summer of 2012 to all Norwegian hospitals that receive trauma patients. These were defined by number of trauma team activations in the included hospitals. A literature review was performed to assess over time the development of hospitals receiving trauma patients. RESULTS Forty-one hospitals responded and were included in the study. In 2011, four trauma centres and 37 acute care hospitals received a total of 6,570 trauma patients. Trauma centres received 2,175 (33%) patients and other hospitals received 4,395 (67%) patients. There were significant regional differences between health care regions in the distribution of trauma patients between trauma centres and acute care hospitals. More than half (52.5%) of the hospitals received fewer than 100 patients annually. The national rate of hospital admission via trauma teams was 13 per 10,000 inhabitants. There was a 37% (from 65 to 41) reduction in the number of hospitals receiving trauma patients between 1988 and 2011. CONCLUSIONS In 2011, hospital acute trauma care in Norway was delivered by four trauma centres and 37 acute care hospitals. Many hospitals still receive a small number of potentially severely injured patients and only a few hospitals have an electronic trauma registry. Future development of the Norwegian trauma system needs to address the challenge posed by a scattered population and long geographical distances. The implementation of a trauma system, carefully balanced between centres with adequate caseloads against time from injury to hospital care, is needed and has been shown to have a beneficial effect in countries with comparable challenges.
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Affiliation(s)
- Oddvar Uleberg
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Trondheim, Norway.
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | | | - Thomas Kristiansen
- Department of Anesthesiology, Vestre Viken HF, Buskerud Hospital, Drammen, Norway.
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.
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Scarpi E, Calistri D, Klepstad P, Kaasa S, Skorpen F, Habberstad R, Nanni O, Amadori D, Maltoni M. Clinical and genetic factors related to cancer-induced bone pain and bone pain relief. Oncologist 2014; 19:1276-83. [PMID: 25342315 DOI: 10.1634/theoncologist.2014-0174] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The study objective was to evaluate whether there are clinical or genetic differences between patients with cancer-induced bone pain (CIBP) and patients with non-CIBP, and, in the CIBP group, in those with good versus poor opioid response. MATERIALS AND METHODS A total of 2,294 adult patients with cancer who were receiving opioids for moderate or severe pain were included in the European Pharmacogenetic Opioid Study. Pain intensity and pain relief were measured using the Brief Pain Inventory. Linkage disequilibrium of 112 single nucleotide polymorphisms was evaluated in 25 candidate genes, and 43 haplotypes were assessed. Correlations among demographical factors, disease-related factors, genetic factors, CIBP, and pain relief were analyzed by logistic regression models corrected for multiple testing. Patients with bone metastases and bone/soft tissue pain were defined as having prevalent bone pain (CIBP population). This population was compared with patients who had other types of cancer pain (non-CIBP). RESULTS A total of 577 patients (26.2%) had CIBP, and 1,624 patients (73.8%) had non-CIBP. Patients with CIBP had more breakthrough cancer pain episodes (64.2% vs. 56.4%, p = .001), had significantly higher pain interference in "walking ability in the past 24 hours" (p < .0001), used more adjuvant drugs (84.1% vs. 78.3%, p = .003), and had a higher, albeit nonsignificant, median overall survival (3.8 vs. 2.9 months, p = .716) than patients with non-CIBP. None of the examined haplotypes exceeded p values corrected for multiple testing for the investigated outcomes. CONCLUSION Patients with CIBP who were taking opioids had a clinical profile slightly different from that of the non-CIBP group. However, no specific genetic pattern emerged for CIBP versus non-CIBP or for responsive versus nonresponsive patients with CIBP.
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Affiliation(s)
- Emanuela Scarpi
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Daniele Calistri
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pål Klepstad
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Stein Kaasa
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Frank Skorpen
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ragnhild Habberstad
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Oriana Nanni
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dino Amadori
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marco Maltoni
- Biostatistics and Clinical Trials Unit, Biosciences Laboratory, Department of Medical Oncology, and Palliative Care Clinic, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola, Italy; Department of Anesthesiology and Intensive Care Medicine and Cancer Clinic, St. Olavs University Hospital, Trondheim, Norway; European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Department of Circulation and Medical Imaging, and Department of Laboratory Medicine, Children's and Women's Health and European Palliative Care Research Centre, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Paulsen Ø, Klepstad P, Rosland JH, Aass N, Albert E, Fayers P, Kaasa S. Efficacy of Methylprednisolone on Pain, Fatigue, and Appetite Loss in Patients With Advanced Cancer Using Opioids: A Randomized, Placebo-Controlled, Double-Blind Trial. J Clin Oncol 2014; 32:3221-8. [DOI: 10.1200/jco.2013.54.3926] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Corticosteroids are frequently used in cancer pain management despite limited evidence. This study compares the analgesic efficacy of corticosteroid therapy with placebo. Patients and Methods Adult patients with cancer receiving opioids with average pain intensity ≥ 4 (numeric rating scale [NRS], 0 to 10) in the last 24 hours were eligible. Patients were randomly assigned to methylprednisolone (MP) 16 mg twice daily or placebo (PL) for 7 days. Primary outcome was average pain intensity measured at day 7 (NRS, 0 to 10); secondary outcomes were analgesic consumption (oral morphine equivalents), fatigue and appetite loss (European Organisation for Research and Treatment of Cancer–Quality of Life Questionnaire C30, 0 to 100), and patient satisfaction (NRS, 0 to 10). Results A total of 592 patients were screened; 50 were randomly assigned, and 47 were analyzed. Baseline opioid level was 269.9 mg in the MP arm and 160.4 mg in the PL arm. At day-7 evaluation, there was no difference between the groups in pain intensity (MP, 3.60 v PL, 3.68; P = .88) or relative analgesic consumption (MP, 1.19 v PL, 1.20; P = .95). Clinically and statistically significant improvements were found in fatigue (−17 v 3 points; P .003), appetite loss (−24 v 2 points; P = .003), and patient satisfaction (5.4 v 2.0 points; P = .001) in favor of the MP compared with the PL group, respectively. There were no differences in adverse effects between the groups. Conclusion MP 32 mg daily did not provide additional analgesia in patients with cancer receiving opioids, but it improved fatigue, appetite loss, and patient satisfaction. Clinical benefit beyond a short-term effect must be examined in a future study.
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Affiliation(s)
- Ørnulf Paulsen
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Pål Klepstad
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Jan Henrik Rosland
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Nina Aass
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Eva Albert
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Peter Fayers
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
| | - Stein Kaasa
- Ørnulf Paulsen, Telemark Hospital Trust, Skien; Ørnulf Paulsen, Pål Klepstad, Peter Fayers, and Stein Kaasa, Norwegian University of Science and Technology; Pål Klepstad and Stein Kaasa, St Olavs Hospital, Trondheim University Hospital, Trondheim; Jan Henrik Rosland, Haraldsplass Deaconess Hospital and University of Bergen, Bergen; Nina Aass, Oslo University Hospital and University of Oslo, Oslo; Eva Albert, Sørlandet Hospital Kristiansand, Kristiansand, Norway; and Peter Fayers, University of Aberdeen,
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Abstract
Chronic postsurgical pain (CPSP) after cardiac surgery represents a significant clinical problem. The prevalence of CPSP varies widely between studies, but severe CPSP is present in less than 10% of the patients. Important differential diagnoses for CPSP after cardiac surgery are myocardial ischemia, sternal instability and mediastinitis. CPSP after cardiac surgery may be thoracic pain present at the site of the sternotomy or leg pain due to vein-graft harvesting. The CPSP can be neuropathic pain, visceral pain, somatic pain or mixed pain. Potential risk factors for CPSP are young age, female gender, overweight, psychological factors, preoperative pain, surgery-related factors and severe postoperative pain. In addition to standard postoperative analgesics, the use of N-methyl-D-aspartate (NMDA) antagonists, alpha-2 agonists, local anesthetics, gabapentinoids, and corticosteroids are all proposed to reduce the risk for CPSP after cardiac surgery. Still, no specific pharmacological therapy, cognitive therapy or physical therapy is established to protect against CPSP. The only convincing prevention of CSPS is adequate treatment of acute postoperative pain irrespective of method. Hence, interventions against acute pain, preferably in a step-wise approach titrating the interventions for each patient's individual needs, are essential concerning prevention of CPSP after cardiac surgery. It is also important that surgeons consider the risk for CPSP as a part of the basis for decision-making around performing a surgical procedure and that patients are informed of this risk.
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Affiliation(s)
- Kari Hanne Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway,
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Affiliation(s)
- Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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90
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Klepstad P. Velskrevet, men til hvilket bruk? Tidsskriftet 2014. [DOI: 10.4045/tidsskr.14.0756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Klepstad P. Polymorphism in the μ-opioid receptor gene OPRM1 A118G -An example of the enigma of genetic variability behind chronic pain syndromes. Scand J Pain 2014; 5:8-9. [PMID: 29913654 DOI: 10.1016/j.sjpain.2013.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Pål Klepstad
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.,St. Olavs HospitalDepartment of Anaesthesiology and Intensive Care Medicine, Trondheim, Norway
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Rao V, Klepstad P, Losvik OK, Solheim O. Confusion with cerebral perfusion pressure in a literature review of current guidelines and survey of clinical practice. Scand J Trauma Resusc Emerg Med 2013; 21:78. [PMID: 24262017 PMCID: PMC3843545 DOI: 10.1186/1757-7241-21-78] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 11/18/2013] [Indexed: 12/31/2022] Open
Abstract
Background Cerebral perfusion pressure (CPP) is defined as the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). However, since patients with traumatic brain injury (TBI) are usually treated with head elevation, the recorded CPP values depends on the zero level used for calibration of the arterial blood pressure. Although international guidelines suggest that target values of optimal CPP are within the range of 50 – 70 mmHg in patients with TBI, the calibration of blood pressure, which directly influences CPP, is not described in the guidelines. The aim of this study was to review the literature used to support the CPP recommendations from the Brain Trauma Foundation, and to survey common clinical practice with respect to MAP, CPP targets and head elevation in European centres treating TBI patients. Methods A review of the literature behind CPP threshold recommendations was performed. Authors were contacted if the publications did not report how MAP or CPP was measured. A short questionnaire related to measurement and treatment targets of MAP and CPP was sent to European neurosurgical centres treating patients with TBI. Results Assessment methods for CPP measurement were only retrieved from 6 of the 11 studies cited in the TBI guidelines. Routines for assessment of CPP varied between these 6 publications. The 58 neurosurgical centres that answered our survey reported diverging routines on how to measure MAP and target CPP values. Higher CPP threshold were not observed if blood pressure was calibrated at the heart level (p = 0.51). Conclusions The evidence behind the recommended CPP thresholds shows no consistency on how blood pressure is calibrated and clinical practice for MAP measurements and CPP target values seems to be highly variable. Until a consensus is reached on how to measure CPP, confusion will prevail.
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Affiliation(s)
- Vidar Rao
- Department of Neurosurgery, St, Olavs Hospital, Trondheim, Norway.
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Sande TA, Scott AC, Laird BJA, Wan HI, Fleetwood-Walker SM, Kaasa S, Klepstad P, Mitchell R, Murray GD, Colvin LA, Fallon MT. The characteristics of physical activity and gait in patients receiving radiotherapy in cancer induced bone pain. Radiother Oncol 2013; 111:18-24. [PMID: 24231246 DOI: 10.1016/j.radonc.2013.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 10/15/2013] [Accepted: 10/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE An objective measure of pain relief may add important information to patients' self assessment, particularly after a treatment. The study aims were to determine whether measures of physical activity and/or gait can be used in characterizing cancer-induced bone pain (CIBP) and whether these biomarkers are sensitive to treatment response, in patients receiving radiotherapy (XRT) for CIBP. MATERIALS AND METHODS Patients were assessed before (baseline) and 6-8weeks after XRT (follow up). The following assessments were done: Brief Pain Inventory (BPI), activPAL™ activity meter, and GAITRite® electronic walkway (measure of gait). Wilcoxon, Mann-Whitney and Pearson statistical analyses were done. RESULTS Sixty patients were assessed at baseline; median worst pain was 7 and walking interference was 5. At follow up 42 patients were assessed. BPI worst pain, average pain, walking interference and total functional interference all improved (p<0.001). An improvement in functional interference correlated with aspects of physical activity (daily hours standing r=0.469, p=0.002) and gait (cadence r=0.341, p=0.03). The activPAL and GAITRite parameters did not change following XRT (p>0.05). In responder analyses there were no differences in activPAL and GAITRite parameters (p>0.05). CONCLUSION Assessment of physical activity and gait allow a characterization of the functional aspects of CIBP, but not in the evaluation of XRT.
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Affiliation(s)
- Tonje A Sande
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Technology and Science (NTNU), Trondheim, Norway.
| | - Angela C Scott
- University of Edinburgh, Edinburgh Cancer Research Centre, United Kingdom
| | - Barry J A Laird
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Technology and Science (NTNU), Trondheim, Norway; University of Edinburgh, Edinburgh Cancer Research Centre, United Kingdom
| | - Hong I Wan
- Pfizer Biotherapeutics, Translational Medicine and Molecular Medicine Clinical Research, Collegeville, United States
| | | | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Technology and Science (NTNU), Trondheim, Norway; Cancer Clinic, St. Olavs Hospital, University Hospital of Trondheim, Trondheim, Norway
| | - Pål Klepstad
- European Palliative Care Research Centre (PRC), Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Technology and Science (NTNU), Trondheim, Norway; St. Olavs Hospital, University Hospital of Trondheim, Department of Anaesthesiology and Emergency Medicine, Trondheim, Norway
| | - Rory Mitchell
- University of Edinburgh, Centre for Integrative Physiology,Edinburgh, United Kingdom
| | - Gordon D Murray
- University of Edinburgh, Centre for Population Health Sciences, Edinburgh, United Kingdom
| | - Lesley A Colvin
- University of Edinburgh, Department of Anaesthesia and Pain Medicine, Western General Hospital, Edinburgh, United Kingdom
| | - Marie T Fallon
- University of Edinburgh, Edinburgh Cancer Research Centre, United Kingdom
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94
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Laird BJ, McMillan DC, Fayers P, Fearon K, Kaasa S, Fallon MT, Klepstad P. The systemic inflammatory response and its relationship to pain and other symptoms in advanced cancer. Oncologist 2013; 18:1050-5. [PMID: 23966223 DOI: 10.1634/theoncologist.2013-0120] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Inflammation has been identified as a hallmark of cancer and may be necessary for tumorgenesis and maintenance of the cancer state. Inflammation-related symptoms are common in those with cancer; however, little is known about the relationship between symptoms and systemic inflammation in cancer. The aim of the present study was to examine the relationship between symptoms and systemic inflammation in a large cohort of patients with advanced cancer. METHODS Data from an international cohort of patients with advanced cancer were analyzed. Symptoms and patient-related outcomes were recorded using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire--Core Questionnaire. Systemic inflammation was assessed using C-reactive protein levels. The relationship between these symptoms and systemic inflammation was examined using Spearman rank correlation (ρ) and the Mann-Whitney U test. RESULTS Data were available for 1,466 patients across eight European countries; 1,215 patients (83%) had metastatic disease at study entry. The median survival was 3.8 months (interquartile range [IQR] 1.3-12.2 months). The following were associated with increased levels of inflammation: performance status (ρ = .179), survival (ρ = .347), pain (ρ = .154), anorexia (ρ = .206), cognitive dysfunction (ρ = .137), dyspnea (p= .150), fatigue (ρ = .197), physical dysfunction (ρ = .207), role dysfunction (ρ = .176), social dysfunction (ρ = .132), and poor quality of life (ρ = .178). All were statistically significant at p < .001. CONCLUSION The results show that the majority of cancer symptoms are associated with inflammation. The strength of the potential relationship between systemic inflammation and common cancer symptoms should be examined further within the context of an anti-inflammatory intervention trial.
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Affiliation(s)
- Barry J Laird
- European Palliative Care Research Centre, Norwegian University of Science and Technology, Trondheim, Norway
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95
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Gjeilo KH, Wahba A, Klepstad P, Lydersen S, Stenseth R. Survival and quality of life in an elderly cardiac surgery population: 5-year follow-up. Eur J Cardiothorac Surg 2013; 44:e182-8. [PMID: 23803508 DOI: 10.1093/ejcts/ezt308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES As survival after cardiac surgery has become very satisfactory even in elderly patients, more attention is being directed towards improved health-related quality of life (HRQOL). However, longitudinal prospective cohort studies describing HRQOL after cardiac surgery are still scarce. The purpose of this study was to explore HRQOL and survival in patients undergoing cardiac surgery after 5 years, emphasizing on older patients (≥75 years). METHODS In a prospective population-based study, 534 patients (23% ≥75 years, 67% males) were consecutively included before surgery. HRQOL and medical and sociodemographic variables were measured by questionnaires at baseline, 6 and 12 months after surgery and again after 5 years. HRQOL was measured by the Short-Form 36 Health Survey (SF-36). RESULTS Four hundred and fifty-eight patients were alive after 5 years, with a response rate of 82%. Older patients had lower 5-year survival than younger patients (P = 0.042), but it was similar to that of the general population. After 5 years, both older and younger patients had slightly lower scores on some SF-36 dimensions, compared with scores after 6 and 12 months. However, on seven of eight subscales of the SF-36, the scores after 5 years were still higher than before surgery. Older patients improved less from baseline to the follow-up, and had more profound reductions in scores from 12 months to 5 years on three subscales; physical functioning (P = 0.013), role physical (P < 0.001) and vitality (P = 0.036). CONCLUSIONS HRQOL improved from baseline to 6 months postoperatively, and remained relatively stable 5 years after cardiac surgery even in elderly patients. The study showed that survival and HRQOL can match that of the general population.
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Affiliation(s)
- Kari Hanne Gjeilo
- Department of Cardiothoracic Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
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96
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Nekolaichuk CL, Fainsinger RL, Aass N, Hjermstad MJ, Knudsen AK, Klepstad P, Currow DC, Kaasa, for the European Palliative S. The Edmonton Classification System for Cancer Pain: Comparison of Pain Classification Features and Pain Intensity Across Diverse Palliative Care Settings in Eight Countries. J Palliat Med 2013; 16:516-23. [DOI: 10.1089/jpm.2012.0390] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cheryl L. Nekolaichuk
- Division of Palliative Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robin L. Fainsinger
- Division of Palliative Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nina Aass
- Regional Centre for Excellence in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Marianne J. Hjermstad
- Regional Centre for Excellence in Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway
- European Palliative Care Research Centre (PRC), Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Pål Klepstad
- European Palliative Care Research Centre (PRC), Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- St. Olav University Hospital, Trondheim, Norway
| | | | - Stein Kaasa, for the European Palliative
- European Palliative Care Research Centre (PRC), Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- St. Olav University Hospital, Trondheim, Norway
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97
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Abstract
BACKGROUND Lung cancer and mesothelioma are malignant tumors with generally dismal prognosis and therefore palliative pain treatment constitutes a challenge for the clinician. OBJECTIVES The aim of this study was to compare the outcomes of pain treatment with opioids among mesothelioma and lung cancer patients treated for palliation and assess factors which confound to optimal treatment. PATIENTS AND METHODS A sub-cohort of 373 lung cancer and 22 mesothelioma patients was identified in multi-center European Pharmacogenetic Opioid Study (EPOS) cohort. A nested case-control (1:4) setting was designed to estimate the pain and other covariates distinguishing 22 mesothelioma- (= cases) and 88 lung cancer patients (controls), analyzed using univariate- and multivariate conditional (fixed-effects) logistic regression models. RESULTS The mean total daily dose of opioids varied from 30.0 to 960.0 mg (mean 275, median 160 mg, SD 293) in mesothelioma, and from 10 to 5072 mg (mean 414, median 175, SD 788) in lung cancer patients (p = 0.420). In both groups, pain was mostly experienced as moderate and severe and it was frequently accompanied by depression, poor sleep, anxiety and fatigue. Four mesothelioma patients (18%) and seven lung cancer patients (10%) experienced complete pain relief with opioids by self-assessment. Assessments of pain severity by the patients and their physicians deviated significantly in mesothelioma (p = 0.039 McNemar test), as well as in lung cancer (p = 0.0001). In conditional logistic regression, no significant differences were found in distribution of pain covariates between lung cancer and mesothelioma patients. CONCLUSION Pain perception by the patients was associated frequently with other symptoms and complete pain control with opioids was achieved only with minority of patients both with mesothelioma and advanced lung cancer. Adequate pain control requires continuous monitoring and tailoring the dose to patient's individual needs and tolerance, recognition of accompanying symptoms such as depression and poor sleep, and their management.
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Affiliation(s)
- Eeva K Salminen
- Department of Oncology and Radiotherapy, Turku University Hospital, Turku, Finland.
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98
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Bjelland TW, Klepstad P, Haugen BO, Nilsen T, Dale O. Effects of Hypothermia on the Disposition of Morphine, Midazolam, Fentanyl, and Propofol in Intensive Care Unit Patients. Drug Metab Dispos 2012; 41:214-23. [DOI: 10.1124/dmd.112.045567] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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99
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Fladvad T, Fayers P, Skorpen F, Kaasa S, Klepstad P. Lack of association between genetic variability and multiple pain-related outcomes in a large cohort of patients with advanced cancer: the European Pharmacogenetic Opioid Study (EPOS). BMJ Support Palliat Care 2012; 2:351-5. [PMID: 24654220 DOI: 10.1136/bmjspcare-2012-000212] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study examined whether the choice of pain-related outcome to represent opioid efficacy influenced findings in a genetic association study. Data from the European Pharmacogenetic Opioid Study, which used opioid dose as the outcome, were analysed in respect of six alternative outcomes: average pain intensity, pain right now, worst pain intensity, pain at its least, pain relief and pain interference. DESIGN Cancer pain patients using an opioid for moderate or severe pain were included. The pain outcomes were obtained using the Brief Pain Inventory. Genetic variation was analysed for 112 single nucleotide polymorphisms (SNPs) in 25 candidate genes relevant for opioid efficacy. The patients were randomly divided into a development and a validation sample and linear regression was used to compare the equality of means in the six outcomes. The influence of non-genetic factors was controlled for, the regression analyses were stratified by country, and the results were corrected for multiple testing. RESULTS 2201 cancer pain patients were included. Their mean age was 62.4 years and mean average pain was 3.5. None of the examined SNPs exceeded p values corrected for multiple testing for any of the outcomes. CONCLUSIONS None of the outcomes were associated with variation in the selected SNPs, as previously shown for opioid dose. Thus, we observed that findings related to associations between genetic variability and opioid efficacy were consistent for several alternative outcomes.
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Affiliation(s)
- Torill Fladvad
- European Palliative Care Research Center (PRC), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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100
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Solheim TS, Fayers PM, Fladvad T, Tan B, Skorpen F, Fearon K, Baracos VE, Klepstad P, Strasser F, Kaasa S. Is there a genetic cause of appetite loss?-an explorative study in 1,853 cancer patients. J Cachexia Sarcopenia Muscle 2012; 3:191-8. [PMID: 22535570 PMCID: PMC3424193 DOI: 10.1007/s13539-012-0064-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 03/20/2012] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Appetite loss has a major impact on cancer patients. It is exceedingly prevalent, is a prognostic indicator and is associated with inferior quality of life. Cachexia is a multi-factorial syndrome defined by a negative protein and energy balance, driven by a variable combination of reduced food intake and abnormal metabolism. Not all cancer patients that experience weight loss have appetite loss, and the pathophysiology between cachexia and appetite loss may thus be different. Knowledge of pathophysiology of appetite loss in cancer patients is still limited. The primary object of this study was to explore the association with 93 predefined candidate single-nucleotide polymorphisms (SNPs) and appetite loss in cancer patients to possibly generate new theories of the pathophysiology of the condition. METHODS A total of 1,853 cancer patients were phenotyped according to appetite loss and then genotyped. RESULTS After allowing for multiple testing, there was no statistically significant association between any of the SNPs analysed and appetite loss. The ten most significant SNPs in the co-dominant model had observed odds ratios varying from 0.72 to 1.28. CONCLUSIONS This large exploratory study could not find any associations with loss of appetite and 93 SNPs with a potential to be involved in appetite loss in cancer patients. This does not however rule out genes putative role in the development of the symptom, but the observed odds ratios are close to one which makes it unlikely that any of the individual SNPs explored in the present study have great importance.
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Affiliation(s)
- Tora S Solheim
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), 7030, Trondheim, Norway,
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