Symptom control in palliative care--Part II: cachexia/anorexia and fatigue

The influence of Chinese herbal medicines on cancer-related pressure ulcer wound, fatigue, constipation, and anorexia: A meta-analysis

We performed a meta-analysis to evaluate the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia. A systematic literature search up to March 2022 was done and 25 studies included 1777 subjects with cancer-related symptoms at the start of the study; 953 of them were provided with Chinese herbal medicines and 824 were control. They were reporting relationships about the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia using the dichotomous method with a random or fixed-effect model. Chinese herbal medicines had significantly higher effectiveness in treating pressure ulcer wound (OR, 5.94; 95% CI, 3.94-8.95, P < .001), fatigue (OR, 2.81; 95% CI, 1.78-4.41, P < .001), and effectiveness on treating constipation (OR, 2.59; 95% CI, 1.57-4.25, P < .001) compared to control in subjects with cancer-related symptoms. However, Chinese herbal medicines had no significant effect on treating anorexia (OR, 1.69; 95% CI, 0.61-4.66, P = .31) compared to control in subjects with cancer-related symptoms. Chinese herbal medicines had significantly higher effectiveness in treating pressure ulcer wound, treating pressure ulcer wound, fatigue, and constipation compared to control in subjects with cancer-related symptoms. However, Chinese herbal medicines had no significant effect on the effectiveness of treating anorexia compared to control in subjects with cancer-related symptoms. Further studies are required to validate these findings.

A randomised, double blind, placebo-controlled trial of megestrol acetate or dexamethasone in treating symptomatic anorexia in people with advanced cancer

This multi-site, double blind, parallel arm, fixed dose, randomised placebo controlled phase III study compared megestrol acetate 480 mg/day with dexamethasone 4 mg/day for their net effects on appetite in people with cancer anorexia. Patients with advanced cancer and anorexia for ≥ 2 weeks with a score ≤ 4 (0–10 numeric rating scale (NRS) 0 = no appetite, 10 = best possible appetite) were recruited. Participants received megestrol 480 mg or dexamethasone 4 mg or placebo daily for up to 4 weeks. Primary outcomes were at day 7. Responders were defined as having a ≥ 25% improvement in NRS over baseline. There were 190 people randomised (megestrol acetate n = 61; dexamethasone n = 67, placebo n = 62). At week 1 (primary endpoint), 79·3% in the megestrol group, 65·5% in the dexamethasone group and 58·5% in the placebo group (p = 0.067) were responders. No differences in performance status or quality of life were reported. Treatment emergent adverse events were frequent (90·4% of participants), and included altered mood and insomnia. Hyperglycemia and deep vein thromboses were more frequent when on dexamethasone than the other two arms. There was no difference in groups between the three arms, with no benefit seen over placebo with anorexia improving in all arms.

Trail registration: The trial was registered on 19/08/2008 with the Australian New Zealand Clinical Trials Registry (ACTRN12608000405314).

Transcriptomic analysis of the development of skeletal muscle atrophy in cancer-cachexia in tumor-bearing mice

Cancer-cachexia (CC) is a wasting condition directly responsible for 20-40% of cancer-related deaths. The mechanisms controlling development of CC-induced muscle wasting are not fully elucidated. Most investigations focus on the postcachectic state and do not examine progression of the condition. We recently demonstrated mitochondrial degenerations precede muscle wasting in time course progression of CC. However, the extent of muscle perturbations before wasting in CC is unknown. Therefore, we performed global gene expression analysis in CC-induced muscle wasting to enhance understanding of intramuscular perturbations across the development of CC. Lewis lung carcinoma (LLC) was injected into the hind-flank of C57BL6/J mice at 8 wk of age with tumor allowed to develop for 1, 2, 3, or 4 wk and compared with PBS-injected control. Muscle wasting was evident at 4 wk LLC. RNA sequencing of gastrocnemius muscle samples showed widespread alterations in LLC compared with PBS animals with largest differences seen in 4 wk LLC, suggesting extensive transcriptomic alterations concurrent to muscle wasting. Commonly altered pathways included: mitochondrial dysfunction and protein ubiquitination, along with other less studied processes in this condition regulating transcription/translation and cytoskeletal structure. Current findings present novel evidence of transcriptomic shifts and altered cellular pathways in CC-induced muscle wasting.

Pain Intervention for people with Dementia in nursing homes (PID): study protocol for a quasi-experimental nurse intervention

BACKGROUND

It is estimated that 19 to 83% of people with dementia suffer from pain that is inadequately treated in the last months of life. A large number of healthcare workers who care for these people in nursing homes lack appropriate expertise and may therefore not always recognise, assess and treat pain in those with dementia who have complex problems on time, properly and efficiently. The aim of this intervention trial is to identify care needs of people with dementia suffering from pain living in a nursing home.

METHODS

A quasi-experimental nurse-led intervention trial based on a convenience sample of four nursing homes in the Swiss Canton of Zurich examines the effects on dementia patients (n = 411), the healthcare institution and the qualification level of the healthcare workers compared to historical controls, using an event analysis and a multilevel analysis. Healthcare workers will be individually trained how to assess, intervene and evaluate acute and chronic pain. There are three data-monitoring cycles (T0, T1, T2) and two intervention cycles (I1, I2) with a total study duration of 425 days. There is also a process evaluation based on Dobbins analyses that analyse in particular the potentials for change in clinical practice of change agents.

DISCUSSION

The aim of the intervention trial is to improve pain management strategies in older people with dementia in nursing homes. Clinically significant findings will be expected that will help reduce suffering in the sense of "total pain" for people with dementia. The joint intra- and interdisciplinary collaboration between practice and supply-oriented (nursing) research will have both a lasting effect on the efficiency measurement and provide scientifically sound results. Nursing homes can integrate the findings from the intervention trial into their internal quality control process. The potential for improvements can be directly influenced by the nursing home itself.

TRIAL REGISTRATION

Registration trial number: DRKS00009726 on DRKS, registered 10 January 2017, retrorespectively registered. Clearance certificate is available of the ethics committees of the canton of Thurgau, Switzerland, number: TG K201-02, and Zurich, Switzerland, number: ZH 01-2016.

Growth differentiating factor-15 (GDF-15): A potential biomarker and therapeutic target for cancer-associated weight loss

Growth differentiating factor-15 (GDF-15), also known as macrophage inhibiting factor-1, is a member of the transforming growth factor-β superfamily, which has been implicated in cancer-associated weight loss. The present study investigated the association between cancer-associated weight loss and plasma GDF-15 concentration, as well as other biomarkers, in patients with metastatic lung or exocrine pancreatic cancer. A total of 218 patients were enrolled over a 1-year period. The patient cohort included 152 patients with incurable lung cancer and 66 patients with incurable pancreatic cancer. Of the 218 patients, 98 (45%) reported >5% weight loss, 62 (28%) reported ≤5% weight loss and 58 (27%) reported no weight loss in the 6 months prior to diagnosis. In lung cancer patients, higher circulating GDF-15 levels were significantly associated with weight loss; lung cancer patients who reported >5% weight loss (n=56) were found to exhibit twice the circulating concentration of GDF-15 compared with those that exhibited no weight loss (n=48) (P<0.0001). Additional mediators, including Activin A, interleukin (IL)-12, vascular endothelial growth factor A, IL-1 receptor α, eotaxin and platelet derived growth factor-BB, were also associated with weight loss; however, the associations were not as strong. In pancreatic cancer patients, no association between GDF-15 levels and weight loss was identified. However, higher circulating GDF-15 levels were consistently associated with poor survival in univariate [hazard ratio (HR), 1.13; 95% confidence interval (CI), 1.02-1.23; P=0.016] and multivariate [HR, 1.1; 95% CI, 1.02-1.24; P=0.03] analysis, respectively. Thus, GDF-15 requires further study as a biomarker and potential therapeutic target in cancer-associated weight loss, particularly in lung cancer patients.

Symptom Frequencies and Intensities in Hospitalized Patients With Advanced Cancer Having Depressive Disorder

Aim:

To explore the frequencies and intensities of depressive symptoms associated with hospitalized patients with advanced cancer.

Methods:

A total of 196 hospitalized patients with advanced cancer were surveyed with the Edmonton Symptom Assessment System and Self-Rating Depression Scale (SDS). The χ2 test and Wilcoxon rank-sum test were used to compare the frequency and intensity of symptoms between patients with and without depressive disorders. Spearman rank correlation was used to test the correlation between depression and symptoms.

Results:

Of the 196 enrolled patients, 115 (59%) were males. The median age of the patients was 58 (19-80) years. Seventy-six (39%) patients were diagnosed with depression (SDS ≥ 53). Patients with depressive disorders exhibited pain, drowsiness, and nausea along with a higher frequency and intensity of poor self-perception, appetite loss, anxiety, dyspnea, and fatigue. Depressive symptoms were positively correlated with the symptoms.

Conclusion:

Depressive disorders are very common and severe in hospitalized patients with advanced cancer. Identifying the frequencies and intensities of the symptoms enables early intervention to improve patients’ quality of life.

Chinese Herbal Medicine for Symptom Management in Cancer Palliative Care: Systematic Review And Meta-analysis

Use of Chinese herbal medicines (CHM) in symptom management for cancer palliative care is very common in Chinese populations but clinical evidence on their effectiveness is yet to be synthesized. To conduct a systematic review with meta-analysis to summarize results from CHM randomized controlled trials (RCTs) focusing on symptoms that are undertreated in conventional cancer palliative care.Five international and 3 Chinese databases were searched. RCTs evaluating CHM, either in combination with conventional treatments or used alone, in managing cancer-related symptoms were considered eligible. Effectiveness was quantified by using weighted mean difference (WMD) using random effect model meta-analysis. Fourteen RCTs were included. Compared with conventional intervention alone, meta-analysis showed that combined CHM and conventional treatment significantly reduced pain (3 studies, pooled WMD: -0.90, 95% CI: -1.69 to -0.11). Six trials comparing CHM with conventional medications demonstrated similar effect in reducing constipation. One RCT showed significant positive effect of CHM plus chemotherapy for managing fatigue, but not in the remaining 3 RCTs. The additional use of CHM to chemotherapy does not improve anorexia when compared to chemotherapy alone, but the result was concluded from 2 small trials only. Adverse events were infrequent and mild. CHM may be considered as an add-on to conventional care in the management of pain in cancer patients. CHM could also be considered as an alternative to conventional care for reducing constipation. Evidence on the use of CHM for treating anorexia and fatigue in cancer patients is uncertain, warranting further research.

Palliative Pharmacotherapy: State-of-the-Art Management of Symptoms in Patients With Cancer

BACKGROUND

Advanced cancer produces multiple symptoms as patients progress through their disease trajectory. Identifying, measuring, and providing therapy for uncontrolled symptoms becomes important because disease-altering therapies may be no longer possible. Symptoms other than pain that cause distress in patients with cancer include delirium, dyspnea, anorexia, nausea, and fatigue. Precise management of these symptoms can lead to the best possible quality of life and lessen distress. This article reviews current management strategies of these symptoms.

METHODS

The epidemiology, mechanisms, assessment, and therapies of common symptoms in the advanced cancer population are reviewed.

RESULTS

Identifiable approaches facilitate symptom management in advanced illness.

CONCLUSIONS

Using a systematic approach to symptoms in advanced illness can improve the quality of life and lessen distress among patients with cancer and their families, friends, and caregivers.

Opportunities for targeting the fatigue-anorexia-cachexia symptom cluster

Cancer patients experience multiple symptoms throughout their illness trajectory. Symptoms consistently occurring together, known as symptom clusters, share common pathophysiologic mechanisms. Understanding and targeting such symptom clusters may allow for more effective and efficient use of treatments for a variety of symptoms. Fatigue-anorexia-cachexia is one of the most prevalent symptom clusters and significantly impairs quality of life. In this review, we explore the fatigue-anorexia-cachexia symptom cluster and focus on current and emerging therapies with an emphasis on pharmacologic management.

Supervised physical exercise to improve the quality of life of cancer patients: the EFICANCER randomised controlled trial

Background

The optimal form of exercise for individuals with cancer has yet to be identified, but there is evidence that exercise improves their quality of life. The aim of this study is to assess the efficacy and efficiency of an innovative physical exercise programme, for individuals undergoing chemotherapy for breast, gastrointestinal or non-small cell lung tumours, for improving quality of life, reducing level of fatigue, and enhancing functional capacity over time.

Design/Methods

We will conduct a clinical trial in 66 patients with stage IV breast, gastrointestinal or non-small cell lung cancer, recruited by the Department of Oncology of the referral hospital from 4 primary care health centres of the Basque Health Service (Osakidetza). These patients will be randomised to one of two groups. The treatment common to both groups will be the usual care for cancer: optimized usual drug therapies and strengthening of self-care; in addition, patients in the intervention group will participate in a 2-month exercise programme, including both aerobic and strength exercises, supervised by nurses in their health centre. The principal outcome variable is health-related quality of life, measured blindly with the 30-item European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire and Short Form-36 four times: at baseline, and 2, 6 and 12 months later. The secondary outcome variables are fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue questionnaire), functional capacity (6-Minute Walk Test and cardiorespiratory test), muscle strength (hand-held dynamometry and sit-to-stand test), radiological response to treatment (Response Evaluation Criteria In Solid Tumors) and progression-free and overall survival. Age, sex, diagnosis, chemotherapy regimen, Eastern Cooperative Oncology Group performance status and smoking status will be considered as predictive variables. Data will be analysed on an intention-to-treat basis, comparing changes at each time point between groups, adjusting for baseline values by analysis of covariance.

Discussion

As well as achieving the objectives set, this study will provide us with information on patient perception of the care received and an opportunity to develop a project based on collaborative action between the primary care and oncology professionals.

Trial registration

ClinicalTrials.gov Identifier: NCT01786122 Registration date: 02/05/2013.

Role of supportive care for terminal stage hepatocellular carcinoma

Patients with end stage or terminal HCC are those presenting with tumors leading to a very poor Performance Status (ECOG 3-4) or Child-Pugh C patients with tumors beyond the transplantation threshold. Among HCC patients, 15-20% present with end stage or terminal stage HCC. Their median survival is less than 3-4 months. The management of end stage or terminal HCC is only symptomatic and no definitive tumor directed treatment is indicated. Patients with end stage or terminal HCC should receive palliative support including management of pain, nutrition and psychological support. In general, they should not be considered for participating in clinical trials. This review focuses on palliative care of terminal stage HCC.

Antifatigue and Antioxidant Activity of Alcoholic Extract from Saussurea involucrata

Fatigue is a noticeable and highly prevalent symptom in tense, industriously, and economically affluent modern society. Therefore, new antifatigue agents to smooth the fatigue feature are an energetic topic. The total ethanol extract (ESI) of Saussurea involucrata Kar et Kir., known as Tian-Shan snow lotus, was evaluated for antifatigue activity in ICR mice with mice forced swimming test and the determination of the contents of blood lactic acid and serum urea nitrogen. ESI (0.05, 0.15, 0.25 g/kg) was administered orally to mice for 4 weeks. The average swimming times to exhaustion of the ESI-treated ICR mice (0.15, 0.25 g/kg) were prolonged by 132% and 180% (p<0.001) with a lessening of fatigue compared with that of the control group. Analysis of biochemical parameters showed that levels of serum urea nitrogen and blood lactic acid of experimental groups were also decreased significantly (p<0.001) compared with that of the control group. The antioxidant activity of ESI was investigated by the 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical-scavenging assay and the hydrogen peroxide-induced luminol chemiluminescence assay and the results indicated that ESI exerts DPPH scavenging ability and reducing power. These results provide scientific evidence that S. involucrata may have been potential as an antifatigue agent.

Feasibility and acceptability of a collaborative care intervention to improve symptoms and quality of life in chronic heart failure: mixed methods pilot trial

BACKGROUND

People with chronic heart failure (HF) suffer from numerous symptoms that worsen quality of life. The CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) intervention was designed to improve symptoms and quality of life by integrating palliative and psychosocial care into chronic care.

OBJECTIVE

Our aim was to determine the feasibility and acceptability of CASA and identify necessary improvements.

METHODS

We conducted a prospective mixed-methods pilot trial. The CASA intervention included (1) nurse phone visits involving structured symptom assessments and guidelines to alleviate breathlessness, fatigue, pain, or depression; (2) structured phone counseling targeting adjustment to illness and depression if present; and (3) weekly team meetings with a palliative care specialist, cardiologist, and primary care physician focused on medical recommendations to primary care providers (PCPs, physician or nurse practioners) to improve symptoms. Study subjects were outpatients with chronic HF from a Veteran's Affairs hospital (n=15) and a university hospital (n=2). Measurements included feasibility (cohort retention rate, medical recommendation implementation rate, missing data, quality of care) and acceptability (an end-of-study semi-structured participant interview).

RESULTS

Participants were male with a median age of 63 years. One withdrew early and there were <5% missing data. Overall, 85% of 87 collaborative care team medical recommendations were implemented. All participants who screened positive for depression were either treated for depression or thought to not have a depressive disorder. In the qualitative interviews, patients reported a positive experience and provided several constructive critiques.

CONCLUSIONS

The CASA intervention was feasible based on participant enrollment, cohort retention, implementation of medical recommendations, minimal missing data, and acceptability. Several intervention changes were made based on participant feedback.

Cancer cachexia--pathophysiology and management

About half of all cancer patients show a syndrome of cachexia, characterized by anorexia and loss of adipose tissue and skeletal muscle mass. Cachexia can have a profound impact on quality of life, symptom burden, and a patient's sense of dignity. It is a very serious complication, as weight loss during cancer treatment is associated with more chemotherapy-related side effects, fewer completed cycles of chemotherapy, and decreased survival rates. Numerous cytokines have been postulated to play a role in the etiology of cancer cachexia. Cytokines can elicit effects that mimic leptin signaling and suppress orexigenic ghrelin and neuropeptide Y (NPY) signaling, inducing sustained anorexia and cachexia not accompanied by the usual compensatory response. Furthermore, cytokines have been implicated in the induction of cancer-related muscle wasting. Cytokine-induced skeletal muscle wasting is probably a multifactorial process, which involves a protein synthesis inhibition, an increase in protein degradation, or a combination of both. The best treatment of the cachectic syndrome is a multifactorial approach. Many drugs including appetite stimulants, thalidomide, cytokine inhibitors, steroids, nonsteroidal anti-inflammatory drugs, branched-chain amino acids, eicosapentaenoic acid, and antiserotoninergic drugs have been proposed and used in clinical trials, while others are still under investigation using experimental animals. There is a growing awareness of the positive impact of supportive care measures and development of promising novel pharmaceutical agents for cachexia. While there has been great progress in understanding the underlying biological mechanisms of cachexia, health care providers must also recognize the psychosocial and biomedical impact cachexia can have.

Assessment of 8-isoprostane (8-isoPGF2α) in urine of non- small cell lung cancer (NSCLC) patients undergoing chemotherapy

8-Isoprostane (8-isoPGF2α) is a reliable marker and considered a gold standard for lipid peroxidation. There are very few reports of 8-isoprostane levels in cancer patients, and in patients undergoing chemotherapy. Oxidative stress is however expected and has been observed in patients with cancer. This study measured 8-isoprostane levels in urine by ELISA of 25 patients undergoing chemotherapy for advanced non-small cell lung cancer, at cycles 1, 2, and 3 of treatment. It considers the creatinine clearance of the patients, and correction of 8-isoprostane levels by creatinine clearance, and overnight urine volume methods. The average 8-isoprostane levels in urine increased more than 6 to 12 fold on chemotherapy treatment, from 532±587 pg/mL at cycle 1, 6181±4334 at cycle 2, and 5511±2055 at cycle 3. Similar results were obtained if 8-isoprostane levels were corrected for overnight urine volume, giving averages of 285±244 μg at cycle 1, 4122±3349 at cycle 2, and 3266±1200 at cycle 3. No significant difference was seen in average total overnight urine volume or number of urinations between chemotherapy cycles except for a large variation in urine volume between cycle 2 and 3. Creatinine levels were significantly different only between cycles 1 and 2 (p=0.016). In conclusion, cisplatin therapy has been shown to induce high levels of lipid peroxidation in lung cancer patients and can be assessed from the 8-isoprostane marker in overnight urine, with or without urine volume correction.

Physical activity and palliative cancer care

Palliative care is an interdisciplinary and holistic approach aimed at alleviating suffering from physical, psychosocial, and spiritual issues in progressive, advanced disease. Progressive fatigue and anorexia-cachexia syndrome can contribute to loss of physical function in the palliative cancer patient, to the detriment of overall quality of life. Physical activity is one potential intervention, which may address these needs in the palliative cancer patient. There is preliminary evidence that at least some palliative cancer patients are willing and able to tolerate physical activity interventions, with some patients demonstrating improvement in select supportive care outcomes postintervention. Methodologically rigorous studies and consensus on common definitions are required to advance this area of research.

Avaliação do instrumento Edmonton Symptom Assessment System em cuidados paliativos: revisão integrativa

Cuidados Paliativos (CP) são prestados a pacientes fora de possibilidades terapêuticas de cura, tendo como foco o controle dos sintomas e melhora da qualidade de vida. A Edmonton Symptom Assessment System (ESAS) é um instrumento para avaliar e monitorar nove sintomas físicos e psicológicos em pacientes de CP. O estudo objetiva realizar revisão integrativa acerca da avaliação dos profissionais de saúde e/ou pacientes quanto ao uso da ESAS em pacientes oncológicos em Cuidados Paliativos. Foram localizados oito artigos no Medical Literature Analysis and Retrieval System Online (MEDLINE) entre 1998 e 2009. Os resultados mostraram que apesar de haver poucos estudos sobre este assunto, a ESAS é um instrumento válido para detectar e monitorar sintomas nos CP, apresentando algumas limitações. Os resultados apontam para a importância da continuidade do estudo de tradução e adaptação transcultural desta escala para o português do Brasil.

Effectiveness of palliative care services in symptom control of patients with advanced terminal cancer: a spanish, multicenter, prospective, quasi-experimental, pre-post study

CONTEXT

In implementing the National Strategy of Palliative Care in Spain, there needs to be an evaluation of services, especially of their effectiveness, efficiency, and satisfaction of patients and families.

OBJECTIVES

To assess the effectiveness of palliative care services (PCS) in improving symptom control in Spain.

METHODS

This multicenter, prospective, quasi-experimental, pre-post intervention study evaluated symptoms, such as pain, breakthrough pain, anorexia, nausea/vomiting, constipation, insomnia, dyspnea at rest and with movement, anxiety, and depression, using patient-reported numeric rating scales on Days 0, 7, and 14 after referral to a PCS.

RESULTS

Of the 318 PCSs included in the National Directory for 2004, 105 services in the 17 autonomous regions of Spain were able to report 265 eligible (treatment-naïve) patients. Nonparticipation by some centers was because of excessive workload or because their patients were not treatment-naïve. Median survival was 42 days. Pain severity and number of crises of breakthrough pain significantly improved, as did other indicators of patient satisfaction. Symptom improvement was independent of type of service (in acute bed hospitals, medium-term stay facilities, hospital support teams, home care support teams, and outpatient clinics).

CONCLUSION

Our national plan appears to be successful in reducing symptoms irrespective of the type of organization providing the PCS. An area for improvement could be to lessen the workload of individual teams.

Palliative care for the cancer patient

Palliation of symptoms to optimize QOL is the foundation of cancer care regardless of stage of disease or level of anticancer treatment. Patients commonly experience pain, constipation, nausea, vomiting, dyspnea, fatigue, and delirium. Many valid clinical tools are available to the primary care clinician to screen for symptoms, assess severity, measure treatment response, and elicit the patient's subjective symptom experience. Although there is limited evidence regarding the relative efficacy of symptom interventions from randomized controlled trials, clinical practice guidelines are available.

Evaluation of psychological and physiological predictors of fatigue in patients with COPD

BACKGROUND

Fatigue in COPD impairs functional status; however there are few studies examining mechanistic pathways of this symptom. The aims of this study are to compare fatigue between COPD patients and healthy age-matched subjects, and to identify predictors of fatigue in COPD.

METHODS

Seventy four COPD patients, mean age 69.9 (49-87) yrs, mean (SD) % predicted FEV1 46.5 (20.0) % and FEV1/FVC ratio 0.45 (0.13) and 35 healthy subjects, mean age 67.1 (50-84) yrs completed the Multidimensional Fatigue Inventory (MFI 20). Patients' assessment included Depression (HADS), lung function, BMI, muscle strength, incremental shuttle walk test (ISWT), exercise oxygen saturation (SpO2), Borg breathlessness (CR-10) and exertion (RPE). Serum level of Interleukin 6 (IL-6) was recorded. Differences in MFI 20 between groups were examined and predictors of fatigue identified using logistic regression.

RESULTS

Significant differences (p < 0.01) were found between the COPD and healthy subjects for all MFI 20 dimensions. There were significant differences when classified according to GOLD and dyspnoea stages for selected dimensions only. Predictors of General Fatigue were depression, muscle strength and end SpO2 (R2 = .62); of Physical Fatigue: depression, % predicted FEV1, ISWT and age (R2 = .57); Reduced Activity: % predicted FEV1, BMI and depression (R2 = .36); Reduced Motivation: RPE, depression and end SpO2 (R2 = .37) and Mental Fatigue: depression and end SpO2 (R2 = .38).

CONCLUSION

All dimensions of fatigue were higher in COPD than healthy aged subjects. Predictive factors differ according to the dimension of fatigue under investigation. COPD-RF is a multi component symptom requiring further consideration.

Symptom burden, depression, and spiritual well-being: a comparison of heart failure and advanced cancer patients

BACKGROUND

A lower proportion of patients with chronic heart failure receive palliative care compared to patients with advanced cancer.

OBJECTIVE

We examined the relative need for palliative care in the two conditions by comparing symptom burden, psychological well-being, and spiritual well-being in heart failure and cancer patients.

DESIGN

This was a cross-sectional study.

PARTICIPANTS

Sixty outpatients with symptomatic heart failure and 30 outpatients with advanced lung or pancreatic cancer.

MEASUREMENTS

Symptom burden (Memorial Symptom Assessment Scale-Short Form), depression symptoms (Geriatric Depression Scale-Short Form), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale).

MAIN RESULTS

Overall, the heart failure patients and the cancer patients had similar numbers of physical symptoms (9.1 vs. 8.6, p = 0.79), depression scores (3.9 vs. 3.2, p = 0.53), and spiritual well-being (35.9 vs. 39.0, p = 0.31) after adjustment for age, gender, marital status, education, and income. Symptom burden, depression symptoms, and spiritual well-being were also similar among heart failure patients with ejection fraction < or =30, ejection fraction >30, and cancer patients. Heart failure patients with worse heart failure-related health status had a greater number of physical symptoms (13.2 vs. 8.6, p = 0.03), higher depression scores (6.7 vs. 3.2, p = 0.001), and lower spiritual well-being (29.0 vs. 38.9, p < 0.01) than patients with advanced cancer.

CONCLUSIONS

Patients with symptomatic heart failure and advanced cancer have similar needs for palliative care as assessed by symptom burden, depression, and spiritual well-being. This implies that heart failure patients, particularly those with more severe heart failure, need the option of palliative care just as cancer patients do.

Symptom management in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) annually causes about one million deaths. Because of advanced stage at diagnosis, HCC carries a five-year survival rate of less than 5% in patients diagnosed with unresectable disease. Incidence for HCC is higher in men and individuals of Asian descent, where viral hepatitis, a leading cause of HCC, is endemic. This article will provide an overview of the complex symptom management of patients with HCC. The occurrence of multiple symptoms, including pain, fatigue, weight loss, and obstructive syndromes (e.g., ascites, jaundice) in patients with HCC is common. Because of limitations in the efficacy of current treatment options, aggressive symptom management is key to preserving physical functioning and quality of life in patients with HCC. A multidisciplinary team approach to symptom management of patients with HCC is critical, with oncology nurses playing an integral role.

Diagnostic criteria of cachexia and their assessment: decreased muscle strength and fatigue

PURPOSE OF REVIEW

The classification of cachexia or wasting disease is currently being revised to improve clinical trial design and clinical care. Decreased muscle strength and fatigue are proposed as diagnostic criteria for cachexia or wasting disease including, but not limited to, cancer. This review discusses their expected value in cancer cachexia.

RECENT FINDINGS

Fatigue is frequent and multifactorial in cancer patients with limited value to predict cachexia, however, most cachectic patients have fatigue. Its assessment requires multimodal subjective instruments, for outcome monitoring many other fatigue cofactors need to be controlled. Cachexia seems a dominant cause for decreased muscle strength. Most cachectic patients lose muscle strength, usually together with reduced muscle mass. High-individual variability of muscle strength limits its use to longitudinal monitoring. Physical activity monitoring, applying also body-worn sensors, offers additional monitoring tools.

SUMMARY

To diagnose and monitor cachexia, muscle strength should be measured directly, whereas fatigue is seen as a global outcome.

Common gastrointestinal symptoms in pediatric palliative care: nausea, vomiting, constipation, anorexia, cachexia

Gastrointestinal symptoms are suffered commonly by children at the end of life. Diagnosis and management of these common symptoms include careful history and physical examination to assess for possible causes; treatment - pharmacologic and nonpharmacologic; and a discussion with patients and families of care goals. Aggressive management of these symptoms is essential to improving the quality of life for these children.