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Pardessus Otero A, Rafecas-Codern A, Porcel JM, Serra-Mitjà P, Ferreiro L, Botana-Rial M, Ramos-Hernández C, Brenes JM, Canales L, Camacho V, Romero-Romero B, Trujillo JC, Martinez E, Cases E, Barba A, Majem M, Güell E, Pajares V. Malignant Pleural Effusion: A Multidisciplinary Approach. OPEN RESPIRATORY ARCHIVES 2024; 6:100349. [PMID: 39091982 PMCID: PMC11293617 DOI: 10.1016/j.opresp.2024.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/10/2024] [Indexed: 08/04/2024] Open
Abstract
Malignant pleural effusion (MPE) has become an increasingly prevalent complication in oncological patients, negatively impacting their quality of life and casting a shadow over their prognosis. Owing to the pathophysiological mechanisms involved and the heterogeneous nature of the underlying disease, this entity is both a diagnostic and therapeutic challenge. Advances in the understanding of MPE have led to a shift in the treatment paradigm towards a more personalized approach. This article provides a comprehensive review and update on the pathophysiology of MPE and describes the diagnostic tools and the latest advances in the treatment of this complex clinical entity.
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Affiliation(s)
- Ana Pardessus Otero
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Albert Rafecas-Codern
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
- Chronic Respiratory Disease Group (GREC), Institut de Recerca Sant Pau (IR SANT PAU), Spain
| | - José M. Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Pere Serra-Mitjà
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Lucía Ferreiro
- Pulmonology Department, University Clinical Hospital of Santiago, Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Maribel Botana-Rial
- Broncopleural Unit, Pulmonary Deparment, Hospital Álvaro Cunqueiro, EOXI Vigo, PneumoVigoI+i Research Group, Sanitary Research Institute Galicia Sur (IISGS), Vigo, Spain
- CIBER de Enfermedades Respiratorias, Spain
| | - Cristina Ramos-Hernández
- Pulmonary Deparment, Hospital Álvaro Cunqueiro, EOXI Vigo, PneumoVigoI+i Research Group, Sanitary Research Institute Galicia Sur (IISGS), Vigo, Spain
| | - José Manuel Brenes
- Radiology Department, Hospital Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Lydia Canales
- Radiology Department, Hospital Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Valle Camacho
- Nuclear Medicine Department, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Carlos Trujillo
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elisabeth Martinez
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Enrique Cases
- Interventional Pulmonology, Hospital Universitario Politécnico La Fe, Valencia, Spain
| | - Andrés Barba
- Medical Oncology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Margarita Majem
- Medical Oncology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Ernest Güell
- Palliative Care Unit, Oncology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma Barcelona (UAB), Barcelona, Spain
| | - Virginia Pajares
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
- Chronic Respiratory Disease Group (GREC), Institut de Recerca Sant Pau (IR SANT PAU), Spain
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2
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Sakaguchi T. Cancer-related breathlessness: opioids other than morphine - comprehensive literature review. BMJ Support Palliat Care 2024; 13:e715-e729. [PMID: 37468224 DOI: 10.1136/spcare-2022-004115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/06/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Although there is low-quality evidence, there has been an increase in publications on the experience of evaluating and managing cancer-related breathlessness using opioids other than morphine. METHODS The author conducted a non-systematic literature review in the PubMed/Medline and Embase until 4 October 2022. Eligible studies have evaluated the efficacy of opioids other than morphine for cancer-related breathlessness. Studies focused on sedation, anaesthesia, paediatric patients, opioid toxicity or basic research were excluded. Reviews/meta-analyses and non-English language publications were also excluded. RESULTS A total of 1556 records were identified, of which 23 studies including 469 patients who were treated with fentanyl (n=223), oxycodone (n=171) and hydromorphone (n=75) were considered eligible. Six phase II randomised clinical trials (RCTs), four observational studies and four case reports of fentanyl were found. For breathlessness on exertion, fentanyl yielded promising results, but no RCT showed significant superiority of fentanyl to placebo or morphine. For terminal breathlessness, three RCTs, five non-randomised or observational studies and one case report on oxycodone or hydromorphone were found. Although the results of the observational studies suggested that oxycodone and hydromorphone might be effective alternatives to morphine, the superiority over placebo or non-inferiority to morphine had not been demonstrated in the RCTs. CONCLUSION As an alternative to morphine, the author recommends fentanyl for breathless crisis or breathlessness on exertion, and oxycodone or hydromorphone for terminal breathlessness in advanced cancer. Larger and well-designed studies based on firm research policies are needed to confirm this current knowledge.
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Affiliation(s)
- Tatsuma Sakaguchi
- Department of Palliative Care, Kitano Hospital, Osaka, Japan
- Palliative Care Centre, Aichi Medical University, Nagakute, Japan
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Jones KF, Abdulhay LB, Orris SR, Merlin JS, Schenker Y, Bulls HW. The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. J Pain Symptom Manage 2022; 64:89-99. [PMID: 35561937 DOI: 10.1016/j.jpainsymman.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. OBJECTIVE To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. METHODS Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). RESULTS Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. DISCUSSION The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing (K.F.J.), Boston College, Chestnut Hill, Massachusetts, USA.
| | - Lindsay Bell Abdulhay
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steve R Orris
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Julià-Torras J, Almeida Felipe JM, Gándara Del Castillo Á, González-Barboteo J, Forero D, Alegre S, Cuervo-Pinna MÁ, Serna J, Muñoz-Unceta N, Alonso-Babarro A, Miró Catalina Q, Moreno-Alonso D, Porta-Sales J. Prevalence, Clinical Characteristics, and Management of Episodic Dyspnea in Advanced Lung Cancer Outpatients: A Multicenter Nationwide Study-The INSPIRA-DOS Study. J Palliat Med 2022; 25:1197-1207. [PMID: 35196465 DOI: 10.1089/jpm.2021.0562] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Episodic dyspnea (ED) is a common problem in patients with advanced lung cancer (LC). However, the prevalence of ED and other related aspects in this patient population is not known. Objectives: To assess and describe the prevalence, clinical features, treatment, and risk factors for ED in outpatients with advanced LC. Design: Multicenter cross-sectional study. Subjects: Consecutive sample of adult outpatients with advanced LC. Measurements: We assessed background dyspnea (BD), the characteristics, triggers, and management of ED. Potential ED risk factors were assessed through multivariate logistic regression. Results: A total of 366 patients were surveyed. Overall, the prevalence of ED was 31.9% (90% in patients reporting BD). Patients reported a median of one episode per day (interquartile range [IQR]: 1-2), with a median intensity of 7/10 (IQR: 5-8.25). ED triggers were identified in 89.9% of patients. ED was significantly associated with chronic obstructive pulmonary disease (p = 0.011), pulmonary vascular disease (p = 0.003), cachexia (p = 0.002), and palliative care (p < 0.001). Continuous oxygen use was associated with higher risk of ED (odds ratio: 9.89; p < 0.001). Opioids were used by 44% patients with ED. Conclusions: ED is highly prevalent and severe in outpatients with advanced LC experiencing BD. The association between intrathoracic comorbidities and oxygen therapy points to alveolar oxygen exchange failure having a potential etiopathogenic role in ED in this population. Further studies are needed to better characterize ED in LC to better inform treatments and trial protocols.
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Affiliation(s)
- Joaquim Julià-Torras
- Palliative Care Department, Institut Català d'Oncologia, Badalona, Spain.,School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - J M Almeida Felipe
- Palliative Care Unit, Complejo Hospitalario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | | | - Jesús González-Barboteo
- Palliative Care Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain.,Palliative Care Research Group, EPIBELL Programme, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat (Barcelona), Spain
| | - Diana Forero
- Palliative Care Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Salvador Alegre
- Internal Medicine Department, Hospital de San Lázaro, Sevilla, Spain
| | | | - Judit Serna
- Support and Palliative Care Unit, Hospital Universitari Campus Vall d'Hebron, Barcelona, Spain
| | - Nerea Muñoz-Unceta
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.,Medical Oncology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVALL), Santander, Spain
| | | | - Queralt Miró Catalina
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain.,Servei d'Atenció Primària Bages-Berguedà-Moianès, Gerència Territorial de Barcelona, Institut Català de la Salut, Manresa, Spain
| | - Deborah Moreno-Alonso
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain.,Palliative Care Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - Josep Porta-Sales
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain.,Universitat Internacional de Catalunya, Sant Cugat del Vallès-Barcelona, Spain
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Karlic KJ, Hummel EK, Houchens N, Meddings J. Use of opioids for refractory dyspnoea in hospitalised patients with serious illness: a narrative review. Postgrad Med J 2021; 99:postgradmedj-2021-140915. [PMID: 34697243 DOI: 10.1136/postgradmedj-2021-140915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/21/2021] [Indexed: 11/04/2022]
Abstract
Refractory dyspnoea can be a challenging symptom to manage. Palliative care specialists are not always available for consultation, and while many clinicians may undergo training in palliative care, this education is not universal. Opioids are the most studied and prescribed pharmacological intervention for refractory dyspnoea; however, many clinicians hesitate to prescribe opioids due to regulatory concerns and fear of adverse effects. Current evidence suggests that rates of severe adverse effects, including respiratory depression and hypotension, are low when opioids are administered for refractory dyspnoea. Therefore, systemic, short-acting opioids are a recommended and safe option for the palliation of refractory dyspnoea in patients with serious illness, especially in a hospital setting that facilitates close observation. In this narrative review, we discuss the pathophysiology of dyspnoea; facilitate an evidence-based discussion on the concerns, considerations and complications associated with opioid administration for refractory dyspnoea; and describe one approach to managing refractory dyspnoea.
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Affiliation(s)
- Kevin J Karlic
- Department of Internal Medicine, Internal Medicine Residency Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Ellen K Hummel
- Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Jennifer Meddings
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Pediatrics and Communicable Diseases, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Zemel RA. Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients. Am J Hosp Palliat Care 2021; 39:847-855. [PMID: 34510917 DOI: 10.1177/10499091211040436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As there is a high propensity for patients with advanced malignancy to experience refractory dyspnea, it is necessary for physicians to be well-versed in the management of these patients' dyspneic symptoms. For symptomatic treatment of cancer patients with dyspnea, both pharmacologic and non-pharmacologic methods should be considered. The main source of pharmacologic symptom management for dyspnea is oral and parenteral opioids; benzodiazepines and corticosteroids may serve as helpful adjuncts alongside opioid treatments. However, oxygen administration and nebulized loop diuretics have not been shown to clinically benefit dyspneic cancer patients. Applying non-pharmacologic dyspnea management methods may be valuable palliative therapies for advanced cancer patients, as they provide benefit with negligible harm to the patient. Advantageous and minimally harmful non-pharmacologic dyspnea therapies include facial airflow, acupuncture and/or acupressure, breathing exercises, cognitive behavioral therapy, music therapy, and spiritual interventions. Thus, it is vital that physicians are prepared to provide symptomatic care for dyspnea in advanced cancer patients as to minimize suffering in this patient population during definitive cancer treatments or hospice care.
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Affiliation(s)
- Rachel A Zemel
- MedStar Georgetown University Hospital, Brookeville, MD, USA
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Aabom B, Laier G, Christensen PL, Karlsson T, Jensen MB, Hedal B. Oral morphine drops for prompt relief of breathlessness in patients with advanced cancer-a randomized, double blinded, crossover trial of morphine sulfate oral drops vs. morphine hydrochloride drops with ethanol (red morphine drops). Support Care Cancer 2019; 28:3421-3428. [PMID: 31792878 DOI: 10.1007/s00520-019-05116-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 10/06/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Episodic breathlessness is frequent in palliative cancer patients. Opioids are the only pharmacological agents with sufficient evidence in treatment. In Denmark, the main recommendation is red morphine drops (RMD), an off-label solution of morphine, ethanol, and red color (cochenille) described since 1893 (Pharmacopoea Danica). In 2015, the Danish Medicines Agency increased focus on off-label medicines and recommended registered morphine drops without ethanol instead. However, our palliative patients told us that RMD was better. For that reason, we conducted a clinical trial to clarify any perceived difference between the two types of drops. METHODS We conducted a randomized, double blinded, crossover trial. Patients were asked to perform standardized activity (2-min walk) aiming to provoke breathlessness. Primary endpoint (breathlessness NRS) and secondary endpoints (saturation, pulse, respiratory frequency) were measured before (t = 0) and after test medicine at t = 1, t = 3, t = 5, t = 10, and t = 20 min. After 2-4 days (washout period), the patients repeated the test, receiving the alternative drops in a blinded setup (crossover). RESULTS In the first 3 min, the relative drop in breathlessness for morphine drops with ethanol (RMD) was significant more than for morphine drops without ethanol. We found no significant difference in secondary endpoints. CONCLUSIONS A conclusion could be that ethanol might facilitate morphine absorption in the mouth. Our results needs further research of opioid absorption in the mouth as well as trials, testing morphine vs. more lipophilic opioids. The RMD drops are cheap, easy to use, and noninvasive and keep the patient independent of health care professionals.
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Affiliation(s)
- Birgit Aabom
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Vestermarksvej 13.1, DK-4000, Roskilde, Denmark.
| | - Gunnar Laier
- Department of Data and Innovation, Region Zealand, Alleen 15, DK-4180, Soroe, Denmark
| | - Poul Lunau Christensen
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Vestermarksvej 13.1, DK-4000, Roskilde, Denmark
| | - Tine Karlsson
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Vestermarksvej 13.1, DK-4000, Roskilde, Denmark
| | - May-Britt Jensen
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Vestermarksvej 13.1, DK-4000, Roskilde, Denmark
| | - Birte Hedal
- Hospice Zealand, Tonsbergvej 61, DK-4000, Roskilde, Denmark
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Dillen K, Ebke M, Koch A, Becker I, Ostgathe C, Voltz R, Golla H. Validation of a palliative care outcome measurement tool supplemented by neurological symptoms (HOPE+): Identification of palliative concerns of neurological patients. Palliat Med 2019; 33:1221-1231. [PMID: 31280657 DOI: 10.1177/0269216319861927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is growing interest to integrate palliative care and its structures into the care of neurological patients. However, in Germany there is no comprehensive assessment tool capturing the symptoms of patients with advanced neurological diseases. AIM To validate a newly developed palliative care measurement tool based on an extension of the validated core documentation system Hospice and Palliative Care Evaluation considering additional neurological issues (HOPE+). DESIGN Prospective, observational study using HOPE+ and as external criteria, the Eastern Cooperative Oncology Group (ECOG) performance status and the 12 months "surprise" question (12-SQ) in a neurological population, and assessment for its construct validity and diagnostic accuracy. SETTING/PARTICIPANTS All newly admitted patients to the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic aged 18-100 years (#DRKS00010947). RESULTS Data from 263 patients (63 ± 14 years of age) were analyzed. HOPE+ revealed a moderately correlated six-factor structure (r = -0.543-0.525). Correlation analysis to evaluate discriminant validity using ECOG as external criterion was high (rs(261) = 0.724, p < 0.001) and confirmed for severely affected patients by adding the 12-SQ ("No"-group: 48.00 ± 14.92 vs "Yes"-group: 18.67 ± 7.57, p < 0.009). Operating characteristics show satisfactory diagnostic accuracy (area under the curve: 0.746 ± 0.049, 95% confidence interval = 0.650-0.842). CONCLUSION HOPE+ demonstrates promising psychometric properties. It helps to assess palliative care issues of patients in neurological settings and, in combination with the 12-SQ, conceivably conditions when to initiate the palliative care approach in a population underrepresented in palliative care structures so far.
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Affiliation(s)
- Kim Dillen
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Markus Ebke
- Neurological Centre for Rehabilitation-MEDIAN-Clinics, Bad Salzuflen, Germany.,Dr. Becker Rhein Sieg Clinic, Nümbrecht, Germany
| | - Andreas Koch
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology (IMSB), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Clinical Trials, University of Cologne, Cologne, Germany.,Center for Health Services Research (ZVFK), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Heidrun Golla
- Department of Palliative Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Center for Integrated Oncology, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
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Kawashima H, Ariizumi T, Yamagishi T, Ogose A, Ikoma M, Hotta T, Endo N. Symptom Burden and End-of-Life Palliative Treatments during the Last Two Weeks of Life in Patients with Advanced Musculoskeletal Sarcoma. J Palliat Med 2019; 22:908-914. [PMID: 30762454 DOI: 10.1089/jpm.2018.0415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Musculoskeletal sarcomas (MSSs) are rare cancers and often aggressive tumors that originate from mesenchymal tissue. Patients with advanced MSS often report difficulties with symptom burden, which can reduce their health-related quality-of-life. Objective: The aim of this study was to describe the patterns of the physical symptoms of MSS patients in the palliative setting and to detail the palliative treatment used in the last two weeks of life. Design: Retrospective study using the electronic patient records from a single institution. Setting/Subjects: A retrospective study was carried out in a sample of 46 consecutive MSS patients with locally advanced/metastatic disease, who were hospitalized and died in our department. The median age of these patients was 56 years at death. Measurements: Symptom burden and medical intervention during the last two weeks of life were collected. Results: The most frequent physical symptoms were pain and dyspnea in 93% and 78% of patients, respectively, while only 17% of patients suffered from nausea. A total of 98% of patients required opioids, and most patients were treated with morphine through either subcutaneous or intravenous continuous injection. Nonsteroidal anti-inflammatory drugs and acetaminophen were administered to 79% of patients. Corticosteroids were administered for the relief of dyspnea to 83% of patients. Of the patients, 46% received palliative chemotherapy within the last two weeks of life, and the oral treatment was continued until a median of 5.6 days before death. In addition, 39% of patients received a sedative treatment during the last two weeks of life for uncontrolled refractory symptoms. Conclusions: The symptom burden experienced by advanced MSS patients is profound at the end of life for all palliative approaches. Therefore, palliative medicine is an important and even crucial component of the continuum of care, allowing for aggressive symptom management with a variety of medical interventions, including palliative sedation.
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Affiliation(s)
- Hiroyuki Kawashima
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan.,2Palliative Care Team, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takashi Ariizumi
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuro Yamagishi
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akira Ogose
- 3Department of Orthopedic Surgery, Uonuma Kikan Hospital, Niigata, Japan
| | - Miho Ikoma
- 2Palliative Care Team, Niigata University Medical and Dental Hospital, Niigata, Japan.,4Division of Palliative Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuo Hotta
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Naoto Endo
- 1Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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10
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Miller D, Nevadunsky N. Palliative Care and Symptom Management for Women with Advanced Ovarian Cancer. Hematol Oncol Clin North Am 2018; 32:1087-1102. [DOI: 10.1016/j.hoc.2018.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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11
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Julià-Torras J, Cuervo-Pinna MÁ, Cabezón-Gutiérrez L, Lara PC, Prats M, Margarit C, Porta-Sales J. Definition of Episodic Dyspnea in Cancer Patients: A Delphi-Based Consensus among Spanish Experts: The INSPIRA Study. J Palliat Med 2018; 22:413-419. [PMID: 30452307 DOI: 10.1089/jpm.2018.0273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Episodic dyspnea is an increasingly recognized phenomenon that occurs frequently in patients with cancer. Although numerous definitions have been proposed to describe episodic dyspnea, to date, no common widely accepted definition in Spanish has yet emerged. Without a clear well-accepted definition, it is difficult to design rigorous clinical trials to evaluate candidate treatments for this emerging entity and to compare outcomes among studies. OBJECTIVE The aim of the study was to reach a consensus definition of episodic dyspnea in the Spanish language based on professional criteria in cancer patients. DESIGN A two-round Delphi study. SETTING/SUBJECTS Sixty-one Spanish specialists in medical oncology, radiation oncology, pneumology, palliative care, and pain management participated in the study. MEASUREMENTS Sixteen different questions on dyspnea-related terminology, including the definition of episodic dyspnea, were assessed. RESULTS The panel of experts reached a consensus on 75% of the 16 assessments proposed: 56.25% in agreement and 18.75% in disagreement. The term that most panelists considered most appropriate to define dyspnea exacerbation was dyspnea crisis. The panelists disagreed that dyspnea exacerbation is equivalent to dyspnea at effort and that the presence of dyspnea at rest is required for exacerbation to occur. However, there was wide agreement that exacerbation may or may not be predictable and can be triggered by comorbidities as well as emotional, environmental, or effort factors. CONCLUSIONS The broad consensus reached in this study is a necessary first step to design high-quality methodological studies to better understand episodic dyspnea and improve treatment.
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Affiliation(s)
- Joaquim Julià-Torras
- 1 Comprehensive Support Service-Palliative Care, Institut Català d'Oncologia , Badalona, Spain
| | | | - Luis Cabezón-Gutiérrez
- 3 Medical Oncology Service, Hospital Universitario de Torrejón , Torrejón de Ardoz, Spain
| | - Pedro C Lara
- 4 Radiation Oncology Service, Hospital Universitario San Roque/Universidad Fernando Pessoa Canarias, Spain
| | - Marisol Prats
- 5 Pneumology Service, Hospital Universitari Germans Trias i Pujol , Badalona, Catalonia, Spain
| | - César Margarit
- 6 Pain Unit, Hospital General Universitario de Alicante , Alicante, Spain
| | - Josep Porta-Sales
- 7 Palliative Care Service, Institut Català d'Oncologia (ICO), Bellvitge Biomedical Research Institute (IDIBELL) , WeCare Chair: End of Life Care, Universitat Internacional de Catalunya, Barcelona, Spain
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Knutsen HK, Alexander J, Barregård L, Bignami M, Brüschweiler B, Ceccatelli S, Cottrill B, Dinovi M, Edler L, Grasl-Kraupp B, Hogstrand C, Hoogenboom LR, Nebbia CS, Oswald IP, Petersen A, Rose M, Roudot AC, Schwerdtle T, Vollmer G, Wallace H, Benford D, Calò G, Dahan A, Dusemund B, Mulder P, Németh-Zámboriné É, Arcella D, Baert K, Cascio C, Levorato S, Schutte M, Vleminckx C. Update of the Scientific Opinion on opium alkaloids in poppy seeds. EFSA J 2018; 16:e05243. [PMID: 32625895 PMCID: PMC7009406 DOI: 10.2903/j.efsa.2018.5243] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Poppy seeds are obtained from the opium poppy (Papaver somniferum L.). They are used as food and to produce edible oil. The opium poppy plant contains narcotic alkaloids such as morphine and codeine. Poppy seeds do not contain the opium alkaloids, but can become contaminated with alkaloids as a result of pest damage and during harvesting. The European Commission asked EFSA to provide an update of the Scientific Opinion on opium alkaloids in poppy seeds. The assessment is based on data on morphine, codeine, thebaine, oripavine, noscapine and papaverine in poppy seed samples. The CONTAM Panel confirms the acute reference dose (ARfD) of 10 μg morphine/kg body weight (bw) and concluded that the concentration of codeine in the poppy seed samples should be taken into account by converting codeine to morphine equivalents, using a factor of 0.2. The ARfD is therefore a group ARfD for morphine and codeine, expressed in morphine equivalents. Mean and high levels of dietary exposure to morphine equivalents from poppy seeds considered to have high levels of opium alkaloids (i.e. poppy seeds from varieties primarily grown for pharmaceutical use) exceed the ARfD in most age groups. For poppy seeds considered to have relatively low concentrations of opium alkaloids (i.e. primarily varieties for food use), some exceedance of the ARfD is also seen at high levels of dietary exposure in most surveys. For noscapine and papaverine, the available data do not allow making a hazard characterisation. However, comparison of the dietary exposure to the recommended therapeutical doses does not suggest a health concern for these alkaloids. For thebaine and oripavine, no risk characterisation was done due to insufficient data. However, for thebaine, limited evidence indicates a higher acute lethality than for morphine and the estimated exposure could present a health risk.
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13
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Maeda T, Hayakawa T. Effect of administered corticosteroids for alleviating dyspnea in patients with terminal cancer: a prospective observational approach. PROGRESS IN PALLIATIVE CARE 2018. [DOI: 10.1080/09699260.2018.1428278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Tsuyoshi Maeda
- Department of Pharmacy, Kasugai Municipal Hospital, Kasugai, Japan
| | - Toru Hayakawa
- Department of Pharmacotherapy, Hokkaido Pharmaceutical University School of Pharmacy, Teine, Sapporo, Japan
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14
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Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Datla S, Dirksen CD, Johnson MJ, van Kuijk SMJ, Wouters EFM, Janssen DJA. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50:50/5/1701153. [PMID: 29167300 DOI: 10.1183/13993003.01153-2017] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/18/2017] [Indexed: 01/19/2023]
Abstract
Previous studies have shown that opioids can reduce chronic breathlessness in advanced disease. However, physicians remain reluctant to prescribe opioids for these patients, commonly due to fear of respiratory adverse effects. The aim of this study was to systematically review reported respiratory adverse effects of opioids in patients with advanced disease and chronic breathlessness.PubMed, Embase, the Cochrane Central Register of Controlled Trials, CINAHL, ClinicalTrials.gov and the reference lists of relevant systematic reviews were searched. Two independent researchers screened against predefined inclusion criteria and extracted data. Meta-analysis was conducted where possible.We included 63 out of 1990 articles, describing 67 studies. Meta-analysis showed an increase in carbon dioxide tension (0.27 kPa, 95% CI 0.08-0.45 kPa,) and no significant change in oxygen tension and oxygen saturation (both p>0.05). Nonserious respiratory depression (definition variable/not stated) was described in four out of 1064 patients. One cancer patient pretreated with morphine for pain needed temporary respiratory support following nebulised morphine for breathlessness (single case study).We found no evidence of significant or clinically relevant respiratory adverse effects of opioids for chronic breathlessness. Heterogeneity of design and study population, and low study quality are limitations. Larger studies designed to detect respiratory adverse effects are needed.
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Affiliation(s)
- Cindy A Verberkt
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Jos M G A Schols
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Dept of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Sushma Datla
- Hull York Medical School, University of Hull, Hull, UK
| | - Carmen D Dirksen
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Sander M J van Kuijk
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Emiel F M Wouters
- CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Daisy J A Janssen
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands
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15
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Maeda T, Hayakawa T. Corticosteroids for alleviating dyspnea in patients with terminal cancer. PROGRESS IN PALLIATIVE CARE 2017. [DOI: 10.1080/09699260.2017.1392674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Tsuyoshi Maeda
- Department of Pharmacy, Kasugai Municipal Hospital, 1-1-1, Takaki-cho, Kasugai, Aichi 486-8510, Japan
| | - Toru Hayakawa
- Department of Pharmacotherapy, Hokkaido Pharmaceutical University School of Pharmacy, 7-15-4-1 Maeda, Teine, Sapporo Hokkaido 006-8590, Japan
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16
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[Special medical problems in end-of-life care : Crisis at the end of life - Which therapy is adequate and when is redefining treatment goals appropriate?]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 60:62-68. [PMID: 27878605 DOI: 10.1007/s00103-016-2477-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Crisis at the end of life are exceptional challenges for patients, relatives and therapists. With respect to the individual treatment goals and the patients' autonomy, therapeutic action should be commenced in an adequate manner in order to preserve the patients' quality of life as much as possible. Advance care planning for specific critical scenarios may be helpful in order to treat patients according to their wishes and values even if they are not capable to express themselves. Furthermore, a crisis plan can define the scope of action for therapists in emergency situations. Dyspnea, pain and delirium are symptoms that may often lead to emergency calls. In such cases, pharmacological and other treatment options are available. Options for causal therapy should be checked and performed if adequate. Opioids are used to relieve pain and dyspnea. In a state of delirium, highly potent neuroleptics and atypical antipsychotics are used. For the treatment of anxiety or restlessness benzodiazepines can be prescribed. Sedative medication may reduce stress, for instance in the case of acute catastrophic bleeding. Palliative sedation is an ultima ratio concept for refractory symptoms at the end of life. Clinical practice guidelines (such as the German guideline "Palliative care for patients with incurable cancer") may provide an overview of the evidence base on symptom-guided therapy at the end of life.
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Palliative care in ovarian carcinoma patients-a personalized approach of a team work: a review. Arch Gynecol Obstet 2017; 296:691-700. [PMID: 28803353 DOI: 10.1007/s00404-017-4484-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/01/2017] [Indexed: 01/06/2023]
Abstract
Most ovarian cancer patients are diagnosed in an advanced stage; and after the initial treatment experience disease recurrence, which eventually becomes palliative. Many questions arise in this setting including how to address patients in the palliative setting, how to discuss end-of-life issues, and how to manage symptoms. In this review, we discuss the timing and setting of end-of-life discussion in the context of end-stage ovarian cancer. We review the approach to relieving disease burden by improving and decreasing symptoms. These symptoms include recurrent ascites, bowel obstruction, pain, pulmonary effusion, and deep vein thrombosis.
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