Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial

Protocol for the treatment of malignant inoperable bowel obstruction: a prospective study of 80 cases at Grenoble University Hospital Center

A prospective protocol for treatment of malignant inoperable bowel obstruction was implemented at Grenoble University Hospital Center for 4 years. All 80 episodes of obstruction resulted from peritoneal carcinomatosis and none could expect another treatment cure. The protocol comprised three successive stages. Stage I included treatment for 5 days with a corticosteroid, antiemetic, anticholinergic, and analgesic. Stage II provided a somatostatin analogue if vomiting persisted. After 3 days, Stage III provided a venting gastrostomy. Obstruction relief with symptom control was obtained by medical treatment in 29 cases and symptom control occurred alone in an additional 32 cases. Ten patients were relieved by venting gastrostomy. Symptom control without permanent nasogastric tube (NGT) placement occurred in 72 episodes (90%). Eight patients with refractory vomiting were obliged to continue the NGT until death. Fifty-eight obstruction episodes (73%) were controlled in 10 days or less. Median time before gastrostomy was 17 days. Median survival was 31 days. This series suggests that a staged protocol for the treatment of inoperable malignant bowel obstruction is highly effective in relieving symptoms. A subgroup experiences relief of obstruction using this approach.

Palliative and shared care concepts in patients with advanced colorectal cancer

Approximately 50% of patients with colorectal cancer (CRC) will eventually die of metastatic disease. Effective palliative management can be used within a shared care model in CRC to provide optimum symptom control, psychological well-being and maintenance of quality of life for patients, their families and carers, including bereavement support. Maintenance of realistic hope and early goal setting are equally important in end-of-life discussions with patients and families. Palliative care should be incorporated early in the course of the illness, concurrent with disease-modifying therapies. Within shared care, the palliative medicine specialist, surgeon and other members of the multidisciplinary team can each bring their own expertise to provide a patient-centred approach. A case is presented that incorporates some of these principles and exemplifies the benefits of contemporary palliative care for patients with advanced CRC.

Management of Symptoms Other than Pain

Symptom management requires an understanding of the likely cause of the symptom in the individual patient, comprehensive assessment, and evidence-based interventions. This article explores the management strategies for common symptoms encountered in palliative care practice. Stomatitis, xerostomia, dysphagia, nausea and vomiting, anorexia, constipation, dyspnea, and fatigue are among the symptoms reviewed.

Effectiveness of pre-emptive metoclopramide infusion in alleviating pain, discomfort and nausea associated with nasogastric tube insertion: a randomised, double-blind, placebo-controlled trial

Aim of this study was to demonstrate that intravenous metoclopramide can reduce pain, nausea and discomfort during nasogastric tube (NGT) insertion in ED. This prospective, randomised, double-blind, placebo-controlled trial was conducted in the university-based ED. One-hundred patients were enrolled. Before NGT insertion, each eligible patient was randomised to one of the two treatment arms: one group received 2 cc of 10 mg IV metoclopramide, whereas others received 2 cc of normal saline. Before and after the procedure, pain, nausea and discomfort were evaluated using 100-mm visual analogue scale (VAS). This study was analysed using the paired sample test, the independent sample test and the chi(2) test. Forty-nine patients received metoclopramide, and 51 received normal saline. Although initial VAS levels elicited for pain, nausea and discomfort were similar, consequent VAS levels of those in the metoclopramide group were significantly lower as compared with those in the normal saline group. The mean differences of VAS levels were statistically significant for three symptoms (p < 0.001). Mean VAS levels of nausea, discomfort and pain during NGT insertion were significantly lower following administration of IV metoclopramide as compared with normal saline.

Traitement de l'occlusion intestinale sur carcinose péritonéale. Étude prospective à propos de 80 cas

AIM

Of the work: evaluation of a multidisciplinary strategy and a prospective medicosurgical protocol for the treatment of occlusion due to unresectable peritoneal carcinomatosis.

PATIENTS AND METHODS

All the included patients had occlusion and intraabdominal carcinomatosis. None could benefit a curative treatment. 75 patients were included for 80 episodes of intestinal obstruction. The protocol involved three successive therapeutic phases. (i) Treatment during five days by corticosteroids associated to antiemetic agents, anticholinergic antisecretory agents, and analgesics as needed (Phase I); (ii) In the event of refractory occlusive symptoms treatment by somatostatin analog during 3 days (phase II); (iii) If this treatment was ineffective a gastrostomy was performed (phase III).

RESULTS

Median survival was 31 days. Outcome showed that for the 80 episodes of obstruction, phase I medical treatment enabled relief in 50 cases (63%) and phase II medical treatment (somatostatin) enabled relief in 11 cases (14%). 10 more patients (13%) were relieved by the gastrostomie and one by a duodenal endoprothesis. Symptom control without a long-term nasogastric tube was achieved for 72 of the 80 episodes (90%). Fifty-eight episodes (72% of overall total) were controlled for 10 days or less. Median time to gastrostomy was 17 days. Eight patients experienced persistent vomiting and required a nasogastric aspiration until death.

CONCLUSION

This multidisciplinary approach between Palliative Care and Specialized Medical and Surgical teams enabled relief of the occlusive symptoms for 90% of the patients of the study. The protocol was useful for the caregivers for the management of terminally ill patients. To enhance these results, it would be necessary to shorten the delay of relief, which has been longer than ten days for one third of the patients. The simplification of the protocol including two steps instead of three is on study.

Cancer pain assessment in clinical trials. A review of the literature (1999-2002)

The aim of this review was to evaluate the methods of pain measurement in controlled clinical trials in oncology published between 1999 and 2002. An electronic literature search strategy was used according to established criteria applied to the Medline database and PubMed search engine. Articles were selected to include only studies that had chronic cancer pain as the primary or secondary objective of a controlled clinical trial. A specific evaluation scheme was used to examine how pain measurement methods were chosen and implemented in the study procedures. The search strategy identified 613 articles, and 68 were selected for evaluation. Most articles (69%) chose unidimensional pain measurement tools, such as visual analogue scales, numerical rating scales and verbal rating scales, whereas others used questionnaires. The implementation of the pain assessment method was problematic in many studies, especially as far as time frame of pain assessment (70%), administration modalities (46%), and use of non-validated measurement methods (10%). Design of study and data analysis were often unclear about the definition of pain outcome measure (40%), patient compliance with pain assessment (98%), and impact of missing data (56%). Statistical techniques were seldom appropriate to the type of data collected and often inadequate to describe the pain variable under study. It is clear from this review that most authors were aware of the need of valid pain measurement tools to be used in clinical trials. However, too often these tools were not appropriately used in the trial, or at least their use was not described with sufficient accuracy in the trial methods.

Treating sialorrhea with transdermal scopolamine. Exploiting a side effect to treat an uncommon symptom in cancer patients

INTRODUCTION

Sialorrhea is a distressing symptom accompanying oral cancer and many heterogeneous cancer-related conditions (chemotherapy-induced nausea, bowel subocclusion, pharmacologic side effects), but its incidence is low in cancer patients. Conversely, it is frequent in patients with neurological damage, and some therapeutic options have been attempted such as botulinum toxins, anticholinergic agents, and surgical procedures.

CASE REPORT

We report the case of an 80-year-old woman with peritoneal carcinomatosis and bowel subocclusion, suffering from distressing nausea and sialorrhea that rapidly improved using transdermal scopolamine. No relevant side effects occurred during the treatment, and the reduction of the abnormal salivation allowed the recovery of oral feeding.

CONCLUSIONS

Anticholinergic drugs are classified as secondary options in the treatment of sialorrhea of patients with Parkinson's disease or cerebral palsy, owing to the relevant side effects occurring during prolonged treatments. However, they could be useful in cancer patients with bowel subocclusion, as the reduction of gastrointestinal secretions and intestinal motility (frequent side effects of anticholinergic drugs) could be effective in controlling nausea, vomiting, and abdominal pain. Moreover, the transdermal or sublingual route of administration can be of some interest, avoiding other more invasive parenteral approaches.

Management of cancer pain

There are four basic approaches to cancer pain control: modify the source of pain, alter central perception of pain, modulate transmission of pain to the central nervous system, and block transmission of pain to the central nervous system. Systemic pharmacologic management aimed at the first three of these approaches is the cornerstone of the treatment of most cancer patients with moderate to severe pain. Optimal pharmacologic management of cancer pain requires selection of the appropriate analgesic drug; prescription of the appropriate dose; administration of the analgesic by the appropriate route; scheduling of the appropriate dosing interval; prevention of persistent pain and relief of breakthrough pain; aggressive titration of the dose of the analgesic; prevention, anticipation, and management of analgesic side effects; consideration of sequential trials of opioid analgesics; and use of appropriate co-analgesic drugs for specific pain syndromes. Most clinicians should be able to control most of the pain in most of their cancer patients. Collaboration with pain and hospice/palliative care experts should help the rest. No cancer patient should live or die with unrelieved pain.

Stability and compatibility of binary mixtures of morphine hydrochloride with hyoscine-n-butyl bromide

The aim of this study was to determine the compatibility and stability of morphine hydrochloride and hyoscine-N-butyl bromide combined in solution at three different concentrations and stored in polypropylene syringes at 4 degrees C and 25 degrees C over a period of 15 days. The doses assayed were 20, 60 and 120 mg/day for morphine hydrochloride and 40, 60 and 80 mg/day for hyoscine-N-butyl bromide. These dose ranges were chosen according to daily practice. At both temperatures, all mixtures can be considered as physically compatible since no evidence of incompatibility-that is precipitation, turbidity, colour change or opacity and gas production-were observed. After 15 days of storage, the percentages of hyoscine-N-butyl bromide remaining in the drug mixtures tested ranged between 96.07% and 92.23%. At the end of the study, the percentages of morphine hydrochloride remaining in the drug mixtures were 100% at both temperatures.

Aggressive pharmacological treatment for reversing malignant bowel obstruction

Early and intensive pharmacological treatment not only may reduce gastrointestinal symptoms but also reverse malignant bowel obstruction. Fifteen consecutive advanced cancer patients with inoperable bowel obstruction received a combination of drugs including metoclopramide, octreotide, dexamethasone and an initial bolus of amidotrizoato. Recovery of intestinal transit was reported within 1-5 days in fourteen patients, who continued this treatment without presenting symptoms of bowel obstruction until death. This case series establishes that the combination of propulsive and antisecretive agents can act synergistically to allow a fast recovery of bowel transit without inducing unpleasant colic. It suggests that the most important mechanism in these circumstances is functional and can be reversible, if an aggressive treatment is initiated early before fecal impaction and edema render bowel obstruction irreversible.

Adjuvant Analgesics in Cancer Pain Management

Adjuvant analgesics are defined as drugs with a primary indication other than pain that have analgesic properties in some painful conditions. The group includes numerous drugs in diverse classes. Although the widespread use of these drugs as first-line agents in chronic nonmalignant pain syndromes suggests that the term "adjuvant" is a misnomer, they usually are combined with a less-than-satisfactory opioid regimen when administered for cancer pain. Some adjuvant analgesics are useful in several painful conditions and are described as multipurpose adjuvant analgesics (antidepressants, corticosteroids, alpha(2)-adrenergic agonists, neuroleptics), whereas others are specific for neuropathic pain (anticonvulsants, local anesthetics, N-methyl-D-aspartate receptor antagonists), bone pain (calcitonin, bisphosphonates, radiopharmaceuticals), musculoskeletal pain (muscle relaxants), or pain from bowel obstruction (octreotide, anticholinergics). This article reviews the evidence supporting the use of each class of adjuvant analgesic for the treatment of pain in cancer patients and provides a comprehensive outline of dosing recommendations, side effects, and drug interactions.

What is the best topical anesthetic for nasogastric insertion? A comparison of lidocaine gel, lidocaine spray, and atomized cocaine

INTRODUCTION

Nasogastric intubation has been shown to be a painful procedure for patients. Previous studies have demonstrated the benefit of topical nasal anesthesia in decreasing the pain of this procedure. This study attempts to identify which of 3 topical anesthetic modalities would be preferred by patients.

METHODS

This study had a double-blind, double-dummy randomized triple crossover design with 30 healthy volunteers as participants. Each participant had 3 nasogastric tubes inserted and acted as his or her own control for the 3 study medications: 1.5 mL 4% atomized lidocaine, 1.5 mL 4% atomized cocaine, and 5 mL 2% lidocaine gel. Participants scored pain of tube passage through the nostril as well as global discomfort. They were also asked to identify which agent they preferred.

RESULTS

In our 30 subjects, although no statistically significant difference in nasal pain scores was found, "global discomfort" was less with the lidocaine gel (P =.017). Participants preferred the lidocaine gel over atomized cocaine (P <.00), but not to a statistically significant degree.

DISCUSSION

Two percent lidocaine gel appeared to provide the best option for a topical anesthetic during nasogastric tube insertion.

Nutrition in advanced digestive cancer

PURPOSE OF REVIEW

The provision of nutrition to patients with advanced digestive cancer, especially those with obstruction, has been an issue discussed by physicians, administrators and patients themselves. There is no real consensus about this topic, perhaps because of the fact that this discussion involves medical, emotional, ethical, economical and legal considerations that are not easily encompassed by any single decision. On the other hand, the quality of life or survival of these patients must be thoroughly evaluated because one of the basic tenets of medicine has always been 'primum non nocere' ('above all, do not harm'). Quality of life itself is a complicated concept because it has no specific definition and varies with each individual and depends upon his/her actual living reality, past experiences, future hopes, dreams and even ambitions.

RECENT FINDINGS

Recent studies have presented controversial results when evaluating the benefits of providing nutritional therapy to patients with advanced digestive cancer with obstruction. Therefore, decision-making should be addressed on an individual basis, but at the same time should be based on defined protocols within each institution. A key factor to be considered is communication among all those involved in the process; most important is the role of the patient and his/her family, who should be able to communicate their feelings, concerns and ethical principles.

SUMMARY

Nutritional therapy in advanced digestive cancer is an instrument that should be evaluated as an extra tool that may offer improved quality of life to those with obstruction, despite the associated increased costs. However, in this delicate matter, our decisions should not be driven by increased pressure by medical system administrators to limit financial expenditure.

Recent advances in malignant bowel obstruction: an interface of old and new

Malignant bowel obstruction continues to be a difficult problem for patients with abdominal and pelvic primary tumors and tumors originating in other sites. The main treatment options consist of surgery, stenting, and pharmacotherapy. Despite recent advances, the impact of available treatment modalities on symptom control, longevity, quality of life, and associated health care costs have not been evaluated rigorously. This article reviews the available data and suggests an approach to the management of this challenging patient population.

Palliative care in a national cancer center: results in 1987 vs. 1993 vs. 2000

In the last few years, palliative care for advanced and terminal cancer patients has undergone considerable evolution. We determined the characteristics of patients admitted to the 4-bed Palliative Care Unit (PCU) of the National Cancer Institute (NCI) of Milan in 1987, 1993 and 2000 to evaluate how our diagnostic and therapeutic approaches have changed over the years. We reviewed the charts of every patient admitted to the PCU in 1987, 1993, and the first ten months of 2000. We recorded demographic data; the primary tumor sites; the main reason for admission; the types of therapies administered (oncologic, analgesic, surgical, neurosurgical analgesic procedures, and supportive therapy); the type and number of cardiological, radiological and endoscopic examinations, as well as specialist consultations; the duration of stay and eventual death on the Unit. There were no significant differences regarding gender, age, primary tumor site and death in hospital of the patients admitted during these years. The time spent in hospital increased over time (P = 0.006). A significant increase was observed in the percentage of patients admitted for supportive therapy (P < 0.001) and investigation concerning the stage of the disease (P < 0.001). There was a significant decrease in admission for invasive analgesic procedures (P < 0.001), as well as for pain diagnosis and/or uncontrolled pain. Uncontrolled pain remained the most frequent reason for admission. Over the years, during hospitalization, 7% to 12% of the patients underwent radiotherapy,1% to 9% had computerized tomography, and 4% to 8% had palliative surgery. More than 50% of the patients received intravenous hydration; a few patients received hypodermoclysis in 1987. Over time, there was a significant increase in "as needed" administration of nonsteroidal anti-inflammatory drugs and a significant reduction in their regular administration (from 24% in 1987 and 1993 to 3% in 2000) (P < 0.001). The use of codeine, tramadol and methadone increased (P < 0.001), whereas the use of oral morphine, buprenorphine and oxycodone decreased in 2000 (P < 0.001). There was a reduction in the use of antidepressants (no significant constant trend) and a significant increase in the use of anticonvulsants, laxatives and pamidronate (P < 0.001). Regularly administered hypnotics decreased in 1993 and increased in 2000 (P < 0.001). Over these years, no significant differences were found in the routes of opioid administration, in route switching and in the mean maximum oral opioid dose (ranging from 108 to 126 mg/day). The percentage of patients undergoing percutaneous cordotomy significantly decreased in 1993 and 2000 (P < 0.001). Over time, there was an increase in requests for specialist consultations, which was significant for neurological, cardiological and oncological consults (P < 0.001). Although the characteristics of the patients admitted to the PCU did not change over these years, there have been significant modifications in our therapeutic approaches, above all in the use of supportive therapy, adjuvant drugs, opioids and neurosurgical invasive procedures. Moreover, a major collaborative interaction with other specialists of the NCI took place with the aim to tailor treatment for each single patient.

Anticipating and treating opioid-associated adverse effects

Opioids are frequently avoided as viable tools in the management of pain due to perceived dangerous or untoward adverse drug events. Whilst they are relatively safe options for the treatment of pain, side effects and toxicities do exist and should be anticipated by the provider. The central nervous, gastrointestinal, genito-urinary, integumentary, metabolic/endocrine, cardiovascular, pulmonary, hepatic/renal, ocular and immune systems all manifest changes associated with opioid therapy. These adverse events, ranging from nuisance to therapy-limiting, are manageable when addressed quickly and appropriately. Opioids are safe and efficacious analgesics when these effects are considered.

Sequential expression of the neuropeptides substance P and somatostatin in granulomas associated with murine cysticercosis

Neurocysticercosis, a parasitic infection of the human central nervous system caused by Taenia solium, is a leading cause of seizures. Seizures associated with neurocysticercosis are caused mainly by the host inflammatory responses to dying parasites in the brain parenchyma. We previously demonstrated sequential expression of Th1 cytokines in early-stage granulomas, followed by expression of Th2 cytokines in later-stage granulomas in murine cysticercosis. However, the mechanism leading to this shift in cytokine response in the granulomas is unknown. Neuropeptides modulate cytokine responses and granuloma formation in murine schistosomiasis. Substance P (SP) induces Th1 cytokine expression and granuloma formation, whereas somatostatin inhibits the granulomatous response. We hypothesized that neuropeptides might play a role in regulation of the granulomatous response in cysticercosis. To test this hypothesis, we compared expression of SP and expression of somatostatin in murine cysticercal granulomas by using in situ hybridization and immunohistochemistry. We also compared expression with granuloma stage. Expression of SP mRNA was more frequent in the early-stage granulomas than in the late-stage granulomas (34 of 35 early-stage granulomas versus 1 of 13 late-stage granulomas). By contrast, somatostatin was expressed primarily in later-stage granulomas (13 of 14 late-stage granulomas versus 2 of 35 early-stage granulomas). The median light microscope grade of SP mRNA expression in the early-stage granulomas was significantly higher than that in the late-stage granulomas (P = 0.008, as determined by the Wilcoxon signed rank test). By contrast, somatostatin mRNA expression was higher at later stages (P = 0.008, as determined by the Wilcoxon signed rank test). SP and somatostatin are therefore temporally expressed in granulomas associated with murine cysticercosis, which may be related to differential expression of Th1 and Th2 cytokines.

Palliative management of malignant bowel obstruction

Bowel obstruction may be a mode of presentation of intra-abdominal and pelvic malignancy or a feature of recurrent disease following anticancer therapy. Malignant bowel obstruction is well-recognized in gynecologic patients with advanced cancer. Retrospective and autopsy studies found the frequency at approximately 5-51% of patients with gynecological malignancy(1-7). Malignant bowel obstruction (MBO) is particularly frequent in patients with ovarian cancer where it is the most frequent cause of death(7). Patients with stage III and IV ovarian cancer and those with high-grade lesions are at higher risk for MBO as compared to patients with lower stage or low-grade tumors(1,8). Ovarian carcinoma accounted for 50% of small bowel obstruction and 37% of large bowel obstruction treated in a large gynecological oncology service(8-11).

Gastrointestinal problems in patients with advanced gynaecological malignancy

Gastrointestinal problems are among the most common problems encountered in the management of women with far advanced gynaecological malignancy. They frequently have a multifactorial aetiology and may require a number of different strategies for effective management. Recognition of the central role of alimentary function in human life is essential to effective treatment. Elucidation of the probable cause of each problem is essential. A thorough knowledge of the natural history of the disease and the patient's current status and future prospects is needed to ensure the highest standard of care for the individual suffering from the problem.