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Lim HS, Yang K, Noh JM, Pyo H, Kim JM, Kwon D, Ju SG, Ahn YC. Reduced frequency and severity of radiation esophagitis without marginal failure risk by contralateral esophagus sparing IMRT in stage III non-small cell lung cancer patients undergoing definitive concurrent chemoradiotherapy. Radiother Oncol 2024; 199:110436. [PMID: 39029592 DOI: 10.1016/j.radonc.2024.110436] [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: 02/20/2024] [Revised: 06/08/2024] [Accepted: 07/10/2024] [Indexed: 07/21/2024]
Abstract
PURPOSE Radiation esophagitis is frequent and annoying toxicity in high dose thoracic radiation therapy. Contalateral esophagus sparing intensity modulated radiation therapy (CES-IMRT) has been proposed to mitigate this problem, and this is to report the impact of CES-IMRT in definitive concurrent chemoradiotherapy (dCCRT) for lung cancer patients. MATERIALS AND METHODS From January 2021 till May 2023, 183 stage III non-small cell lung cancer patients underwent dCCRT. Esophagus was located within 1 cm from internal target volume in 159 patients. We comparatively evaluated the frequency and severity of esophagitis by pain-killer usage, analgesic quantification algorithm (AQA) score, and failure patterns in 159 CES-necessary patients. RESULTS All patients underwent dCCRT (66 Gy in 30 fractions with concurrent chemotherapy). Actual CES-IMRT application was determined based on the discretion of responsible radiation oncologists: CES-applied in 41 patients; and CES-unapplied in 118. CES-applied patients experienced pain events less frequently (pain-killer usage: 53.7 % vs. 77.1 %, p = 0.008) and less severely (AQA score of 2-3: 39.0 % vs. 68.6 %, p = 0.002). On multivariate analyses, overlapping volume of esophagus and planning target (HR = 1.32, 95 % CI 1.12-1.55, p = 0.001) and CES-IMRT application (HR = 0.31, 95 % CI 0.13-0.76, p = 0.010) were associated with AQA score of 2-3 less frequently. There were no differences in failure pattern, progression-free survival, and overall survival. CONCLUSIONS CES-IMRT application resulted in less frequent and less severe pain events without compromising oncologic outcomes. Further studies, preferably in a randomized fashion, would be desired.
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Affiliation(s)
- Hae Sol Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Kyungmi Yang
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea.
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Jin Man Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Dongyeol Kwon
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Sang Gyu Ju
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Yong Chan Ahn
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea.
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Ing MC, Keane OA, Lakshmanan A, Kim E, Lee HC, Kelley-Quon LI. Opioid equipotency conversions for hospitalized infants: a systematic review. J Perinatol 2024:10.1038/s41372-024-02121-z. [PMID: 39304731 DOI: 10.1038/s41372-024-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 09/05/2024] [Accepted: 09/13/2024] [Indexed: 09/22/2024]
Abstract
Hospitalized infants commonly receive opioids to reduce pain and minimize distress during invasive procedures. However, infant neurodevelopment is significantly impacted by cumulative and prolonged opioid exposures. While opioid conversion has been studied extensively in adults, no standardized equipotency opioid conversions exist for hospitalized infants and opioid stewardship efforts are inconsistent. We performed a systematic review to identify opioid dosing conversions commonly used in hospitalized infants <1 year of age, finding fourteen articles which documented or cited a calculation of cumulative opioid exposure. Morphine milligram equivalents (MME) conversion factors varied widely, with nine studies citing conversion equivalent equations commonly used in adults. Efforts to expand safe opioid stewardship to hospitalized infants will require evidence-based consensus for opioid equipotency dose conversions which acknowledge the unique physiology of infants.
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Affiliation(s)
- Madeleine C Ing
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Ashwini Lakshmanan
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Henry C Lee
- Division of Neonatology, University of California San Diego, La Jolla, CA, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California, USA.
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Clarke NA, Wong B, Lawrance R, Ingelgård A, Griebsch I, Cella D, Trigg A. Validity, reliability, responsiveness, and clinically meaningful change threshold estimates of the National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index (NFBSI-16). J Patient Rep Outcomes 2024; 8:97. [PMID: 39145900 PMCID: PMC11327234 DOI: 10.1186/s41687-024-00776-y] [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: 07/10/2023] [Accepted: 08/01/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Breast cancer is one of the most common cancers in women. Patient-reported outcome measures are used to evaluate patients' health-related quality of life in clinical breast cancer studies. This study evaluated the structure, validity, reliability, and responsiveness of the National Comprehensive Cancer Network-Functional Assessment of Cancer Therapy-Breast Cancer Symptom Index (NFBSI-16) subscales in a clinical trial featuring patients with advanced/metastatic breast cancer (aBC), and estimated NFBSI-16 meaningful change thresholds. METHODS Data from 101 patients with aBC enrolled in a phase II trial (Xenera-1) were included for psychometric evaluation of the NFBSI-16. Subscale structure was evaluated by assessing inter-item correlations, item-total correlations, and internal consistency (cycles 2 and 5). Validity was assessed using scale-level convergent validity (cycles 2 and 5) and known-groups (Baseline). Reliability was analysed via test-retest at cycles 3-4, and responsiveness to improvement and worsening was evaluated at cycles 5, 7, and 9. Meaningful change thresholds were estimated using anchor-based methods (supported by distribution-based methods) at cycles 5, 7, and 9. RESULTS NFBSI-16 internal consistency was acceptable, but item-total correlations suggested that its subscales and the GP5 item (side-effect of treatment) scores may be preferred over a total score. Convergent and known-groups evidence supported NFBSI-16 validity. Test-retest reliability was good to excellent for Total and DRS-P (disease-related symptoms: physical) scales, and moderate for the GP5 item. Responsiveness to worsening was generally demonstrated, but responsiveness to improvement could not be demonstrated due to limited observed improvement. Anchor-based meaningful change thresholds were estimated for DRS-P and Total scores. CONCLUSION This study provides evidence that the NFBSI-16 has desirable psychometric properties for use in clinical studies in aBC. It also provides estimates of group- and individual-level meaningful change thresholds to facilitate score interpretation in future aBC research.
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Affiliation(s)
- Nathan A Clarke
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, SK10 5JB, UK.
| | - Brendon Wong
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Rachael Lawrance
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, SK10 5JB, UK
| | - Anders Ingelgård
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Ingolf Griebsch
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Andrew Trigg
- Adelphi Values, Adelphi Mill, Bollington, Cheshire, SK10 5JB, UK
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Coleman PW, Underriner TC, Kennerley VM, Marshall KD. Transitioning from intrathecal bupivacaine to mepivacaine for same-day discharge total joint arthroplasty: a quality improvement study. Reg Anesth Pain Med 2024; 49:254-259. [PMID: 37433742 DOI: 10.1136/rapm-2023-104378] [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: 01/30/2023] [Accepted: 06/23/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Same-day discharge total knee and hip arthroplasty is becoming more common. Anesthetic approaches that optimize readiness for discharge are important. Based on an institutional change from low-dose bupivacaine to mepivacaine, we aimed to assess the impact on postanesthesia care unit (PACU) recovery in a quaternary care, academic medical center. METHODS In this quality improvement retrospective study, a single surgeon performed 96 combined total knee and hip arthroplasties booked as same-day discharge from September 20, 2021 to December 20, 2021. Starting on November 15, 2021 the subarachnoid block was performed with isobaric mepivacaine 37.5-45 mg instead of hyperbaric bupivacaine 9-10.5 mg. We compare these cohorts for time to discharge from PACU, perioperative oral morphine milligram equivalent (OMME) administration, PACU pain scores, conversion to general anesthesia (GA), and overnight admission. RESULTS We found the use of isobaric mepivacaine as compared with hyperbaric bupivacaine for intrathecal block in same-day discharge total joint arthroplasty was associated with decreased length of PACU stay at our academic center (median 4.03 vs 5.33 hours; p=0.008), increased perioperative OMME (mean 22.5 vs 11.4 mg; p<0.001), increased PACU pain scores (mean 6.29 vs 3.41; p<0.01) and no difference in conversion to GA or overnight admission. CONCLUSIONS Intrathecal mepivacaine was associated with increased perioperative OMME consumption and PACU pain scores, but still realized a decreased PACU length of stay.
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Affiliation(s)
- Peter W Coleman
- Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Tyler C Underriner
- Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Victoria M Kennerley
- Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kyle D Marshall
- Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Lehto PM, Kortekangas T, Vakkala M, Ohtonen P, Nyman ES, Karvonen K, Liisanantti J, Kaakinen TI. The effect of tourniquet use on postoperative opioid consumption after ankle fracture surgery - a retrospective cohort study. Scand J Pain 2024; 24:sjpain-2023-0051. [PMID: 38126186 DOI: 10.1515/sjpain-2023-0051] [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: 04/22/2023] [Accepted: 10/30/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES A pneumatic tourniquet is often used during ankle fracture surgery to reduce bleeding and enhance the visibility of the surgical field. Tourniquet use causes both mechanical and ischemic pain. The main purpose of this study was to evaluate the effect of tourniquet time on postoperative opioid consumption after ankle fracture surgery. METHODS We retrospectively reviewed the files of 586 adult patients with surgically treated ankle fractures during the years 2014-2016. We evaluated post hoc the effect of tourniquet time on postoperative opioid consumption during the first 24 h after surgery. The patients were divided into quartiles by the tourniquet time (4-43 min; 44-58 min; 59-82 min; and ≥83 min). Multivariable linear regression analysis was used to evaluate the results. RESULTS Tourniquets were used in 486 patients. The use of a tourniquet was associated with an increase in the total postoperative opioid consumption by 5.1 mg (95 % CI 1.6-8.5; p=0.004) during the first 24 postoperative hours. The tourniquet time over 83 min was associated with an increase in the mean postoperative oxycodone consumption by 5.4 mg (95 % CI 1.2 to 9.7; p=0.012) compared to patients with tourniquet time of 4-43 min. CONCLUSIONS The use of a tourniquet and prolonged tourniquet time were associated with higher postoperative opioid consumption during the 24 h postoperative follow-up after surgical ankle fracture fixation. The need for ethical approval and informed consent was waived by the Institutional Review Board of Northern Ostrobothnia Health District because of the retrospective nature of the study.
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Affiliation(s)
- Pasi M Lehto
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Tero Kortekangas
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Merja Vakkala
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Pasi Ohtonen
- Research Service Unit, Oulu University Hospital, Oulu, Finland
| | - Emma-Sofia Nyman
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Kaisu Karvonen
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Timo I Kaakinen
- Research Group of Surgery, Anaesthesiology and Intensive Care, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
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Sorrentino ZA, Desai A, Eisinger RS, Maciel CB, Busl KM, Lucke-Wold B. Evaluating analgesic medications utilized in the treatment of aneurysmal subarachnoid hemorrhage and association with delayed cerebral ischemia. J Clin Neurosci 2023; 115:157-162. [PMID: 37579712 DOI: 10.1016/j.jocn.2023.07.023] [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: 04/24/2023] [Revised: 07/16/2023] [Accepted: 07/26/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) recovery may be hampered by delayed cerebral ischemia (DCI). Herein, we sought to identify whether frequently administered medications in the intensive care unit (ICU) are associated with DCI. METHODS In this retrospective study, patients admitted to a tertiary care center neuro-ICU between 2012 and 2019 with aSAH who could verbalize pain intensity scores were included. Medication dosages and clinical characteristics were abstracted from the medical record. Both paired and unpaired analyses were utilized to measure individual DCI risk for a given patient in relation to drug dosages. RESULTS 119 patients were included; average age was 61.7 ± 15.2 (SD) years, 89 (74.7%) were female, and 32 (26.9%) experienced DCI during admission. Patients with DCI had longer length of stay (19.3 ± 7.4 vs 12.7 ± 5.3 days, p < 0.0001). The combination medication of acetaminophen 325 mg/butalbital 50 mg/caffeine 40 mg (A/B/C) was associated with decreased DCI on paired (2.3 ± 2.0 vs 3.1 ± 1.9 tabs, p = 0.034) and unpaired analysis (1.84 ± 2.4 vs 2.6 ± 2.4 tabs, p < 0.001). No associations were found between DCI and opioids, dexamethasone, levetiracetam, or acetaminophen. Max and mean daily headache pain was not associated with DCI occurrence. CONCLUSION We identified an association between a commonly administered analgesic and DCI. A/B/C is associated with decreased DCI in this study, while other medications are not associated with DCI risk.
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Affiliation(s)
- Zachary A Sorrentino
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Ansh Desai
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | | | - Carolina B Maciel
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurology, Yale University, New Haven, CT, USA; Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Katharina M Busl
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, FL, USA
| | - Brandon Lucke-Wold
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Harsanyi H, Yang L, Harper A, Jarada TN, Quan ML, Cheung WY, Lupichuk S, Cuthbert C, Xu Y. Improvement in patient-reported pain among patients with metastatic cancer and its association with opioid prescribing. Support Care Cancer 2023; 31:427. [PMID: 37369812 DOI: 10.1007/s00520-023-07893-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE Opioids are a mainstay of cancer pain management; however, patients with metastatic cancer are often excluded from studies, leading to a lack of evidence on whether increased prescribing (dosage and/or duration) results in improved outcomes for this population. This study aimed to investigate whether increased opioid prescribing is associated with an improvement in patient-reported pain among patients with metastatic cancer. PATIENTS AND METHODS A retrospective cohort of all adult patients diagnosed with stage IV cancers, who completed at least two patient-reported outcomes (PROs) within 30 days of each other, was identified from administrative data. Opioid prescriptions were categorized by dosage level and number of prescription days. Multivariable logistic regression was used to investigate the association between opioid prescribing and clinically important improvement in pain score (≥ 1 point change on the Edmonton Symptom Assessment System). RESULTS A total of 2169 patients were included, 770 (35.5%) of whom had active opioid prescription between PROs, with an average daily dosage of 86.1 mg of oral morphine equivalent. Active prescription was associated with improvement in pain (OR = 2.17, P < 0.001). However, among patients with active prescription, neither dosage nor number of prescription days was significantly associated with pain improvement. CONCLUSION Opioid prescription is important for treating cancer-related pain; however, increased dosage or duration may not be leading to greater improvements in pain. Patients with metastatic cancer who are receiving increased opioid prescribing may have difficult-to-treat pain and may benefit from multidisciplinary pain management strategies to supplement opioid prescription and improve outcomes.
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Affiliation(s)
- Hannah Harsanyi
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
| | - Lin Yang
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Andrew Harper
- Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, AB, Canada
| | - Tamer N Jarada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - May Lynn Quan
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Winson Y Cheung
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Sasha Lupichuk
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Colleen Cuthbert
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Yuan Xu
- Department of Community Health Sciences, Foothills Medical Centre, University of Calgary, HRIC 2AA18, 3230, Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
- Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- The Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Dexamethasone Coanalgesic Administration in Steroid Naïve and Steroid Non-Naïve Patients for the Prevention of Pain Flares after Palliative Radiotherapy for Bone Metastases. Pain Res Manag 2022; 2022:6153955. [PMID: 36479161 PMCID: PMC9722317 DOI: 10.1155/2022/6153955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/29/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022]
Abstract
Objective Dexamethasone could be an effective prophylactic agent for the prevention of pain flares after palliative radiotherapy (RT) for uncomplicated bone metastases. To date, there are no data on its prophylactic coanalgesic (opioid-sparing) effect after RT in patients with complicated bone metastases compared to uncomplicated ones, which is the aim of our study. Methods Twenty-nine American Society of Anaesthesiologists (ASA) III-IV patients, aged ≥18, treated with single-fraction 8 Gy/1 or multi-fraction 20 Gy/5 RT for painful uncomplicated bone metastases (steroid naïve patients, n = 14) or complicated ones (steroid non-naïve patients, n = 15), were examined retrospectively. All patients received parenteral dexamethasone (4 mg or 8 mg daily, 1 hour before RT, followed by the same dose for the next 4 days) along with their background and breakthrough pain opioid intake (morphine equivalents) during their 5-day in-hospital stay. Pain severity (numeric rating scale) and analgesic consumption were recorded at admission, daily during the hospital stay, and for 10 days following treatment. Binary logistic regression was used to determine predictive factors for pain flare occurrence. Results A higher ASA score is the only determinant positively influencing opioid consumption (P = 0.018) and pain flare as well (OR = 15.00; 95% CI: 2, 24-100, 48; P = 0.005). Lower dose 4 mg dexamethasone was revealed as a moderate analgesic agent in steroid naïve patients with no side effects, whereas in steroid non-naïve patients the predominantly higher dose 8 mg dexamethasone had minimal impact on pain flares prevention at the expense of more pronounced immunosuppression (P = 0.039). Conclusions Irrespective of the supporting evidence of dexamethasone potential for prevention of RT-induced pain flare, our data failed to reveal its efficacy in the real practice world (a case mix of uncomplicated and complicated bone metastases). Further dose-effect bigger studies are needed, identifying optimal doses of dexamethasone intake and its optimal duration in high-risk patients.
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Tsai HI, Lu YC, Zheng CW, Yu MC, Chou AH, Lee CH, Kou HW, Lin JR, Lai YH, Chang LL, Lee CW. A Retrospective Comparison of Three Patient-Controlled Analgesic Strategies: Intravenous Opioid Analgesia Plus Abdominal Wall Nerve Blocks versus Epidural Analgesia versus Intravenous Opioid Analgesia Alone in Open Liver Surgery. Biomedicines 2022; 10:2411. [PMID: 36289673 PMCID: PMC9598303 DOI: 10.3390/biomedicines10102411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Adequate pain control is of crucial importance to patient recovery and satisfaction following abdominal surgeries. The optimal analgesia regimen remains controversial in liver resections. Methods: Three groups of patients undergoing open hepatectomies were retrospectively analyzed, reviewing intravenous patient-controlled analgesia (IV-PCA) versus IV-PCA in addition to bilateral rectus sheath and subcostal transversus abdominis plane nerve blocks (IV-PCA + NBs) versus patient-controlled thoracic epidural analgesia (TEA). Patient-reported pain scores and clinical data were extracted and correlated with the method of analgesia. Outcomes included total morphine consumption and numerical rating scale (NRS) at rest and on movement over the first three postoperative days, time to remove the nasogastric tube and urinary catheter, time to commence on fluid and soft diet, and length of hospital stay. Results: The TEA group required less morphine over the first three postoperative days than IV-PCA and IV-PCA + NBs groups (9.21 ± 4.91 mg, 83.53 ± 49.51 mg, and 64.17 ± 31.96 mg, respectively, p < 0.001). Even though no statistical difference was demonstrated in NRS scores on the first three postoperative days at rest and on movement, the IV-PCA group showed delayed removal of urinary catheter (removal on postoperative day 4.93 ± 5.08, 3.87 ± 1.31, and 3.70 ± 1.30, respectively) and prolonged length of hospital stay (discharged on postoperative day 12.71 ± 7.26, 11.79 ± 5.71, and 10.02 ± 4.52, respectively) as compared to IV-PCA + NBs and TEA groups. Conclusions: For postoperative pain management, it is expected that the TEA group required the least amount of opioid; however, IV-PCA + NBs and TEA demonstrated comparable postoperative outcomes, namely, the time to remove nasogastric tube/urinary catheter, to start the diet, and the length of hospital stay. IV-PCA with NBs could thus be a reliable analgesic modality for patients undergoing open liver resections.
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Affiliation(s)
- Hsin-I Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Chieh Lu
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Chih-Wen Zheng
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Ming-Chin Yu
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
- Department of Surgery, New Taipei Municipal Tu-Cheng Hospital (Built and Operated by Chang Gung Medical Foundation), Tu-Cheng, New Taipei City 236, Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Cheng-Han Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Hua Lai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Li-Ling Chang
- Department of Nursing, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
| | - Chao-Wei Lee
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan 333, Taiwan
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Eisinger RS, Sorrentino ZA, Lucke-Wold B, Zhou S, Barlow B, Hoh B, Maciel CB, Busl KM. Severe headache trajectory following aneurysmal subarachnoid hemorrhage: the association with lower sodium levels. Brain Inj 2022; 36:579-585. [PMID: 35353644 PMCID: PMC9177668 DOI: 10.1080/02699052.2022.2055146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND A clinical hallmark of aneurysmal SAH (aSAH) is headache. Little is known about post-aSAH headache factors which may point to underlying mechanisms. In this study, we aimed to characterize the severity and trajectory of headaches in relation to clinical features of patients with aSAH. METHODS This is a retrospective longitudinal study of adult patients admitted to an academic tertiary care center between 2012 and 2019 with aSAH who could verbalize pain scores. Factors recorded included demographics, aneurysm characteristics, analgesia, daily morning serum sodium concentration, and occurrence of vasospasm. Group-based trajectory modeling was used to identify headache pain trajectories, and clinical factors were compared between trajectories. RESULTS Of 91 patients included in the analysis, mean age was 57 years and 20 (22%) were male. Headache score trajectories clustered into two groups: patients with mild-moderate and moderate-severe pain. Patients in the moderate-severe pain group were younger (P<0.05), received more opioid analgesia (P<0.001), and had lower sodium concentrations (P<0.001) than patients in the mild-moderate pain group. CONCLUSION We identified two distinct post-aSAH headache pain trajectory cohorts and identified an association with age, analgesia, and sodium levels. Future prospective studies considering sodium homeostasis and volume status under standardized analgesic regimens are warranted.
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Affiliation(s)
- Robert S Eisinger
- University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sonya Zhou
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brooke Barlow
- Department of Pharmacy, University of Florida Shands Hospital, Gainesville, Florida, USA
| | - Brian Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Carolina B Maciel
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida USA
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Katharina M Busl
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Gainesville, Florida USA
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11
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Lehto PM, Vakkala MA, Alahuhta S, Liisanantti JH, Kortekangas THJ, Hiltunen K, Nyman E, Kaakinen TI. Difference in postoperative opioid consumption after spinal versus general anaesthesia for ankle fracture surgery-A retrospective cohort study. Acta Anaesthesiol Scand 2021; 65:1109-1115. [PMID: 33963533 DOI: 10.1111/aas.13845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical treatment of ankle fracture is associated with significant pain and high postoperative opioid consumption. The anaesthesia method may affect early postoperative pain. The main objective of the study was to compare postoperative opioid consumption after ankle-fracture surgery between patients treated with spinal anaesthesia and general anaesthesia. METHODS We reviewed retrospectively the files of 586 adult patients with surgically treated ankle fracture in the years 2014 through 2016. The primary outcome was opioid consumption during the first 48 postoperative hours. Secondary outcomes were maximal pain scores, postoperative nausea and vomiting, the length of stay in the post-anaesthesia care unit, and opioid use in different time periods up to 48 h postoperatively. Propensity score matching was used to mitigate confounding variables. RESULTS Total opioid consumption 48 h postoperatively was significantly lower after spinal anaesthesia (propensity score-matched population: effect size -13.7 milligrams; 95% CI -18.8 to -8.5; P < .001). The highest pain score on the numerical rating scale in the post-anaesthesia care unit was significantly higher after general anaesthesia (propensity score-matched population: effect size 3.7 points; 95% CI 3.2-4.2; P < .001). A total of 60 patients had postoperative nausea and vomiting in the post-anaesthesia care unit, 53 (88.3%) of whom had general anaesthesia (P = .001). CONCLUSIONS Patients with surgically treated ankle fracture whose operation was performed under general anaesthesia used significantly more opioids in the first 48 h postoperatively, predominantly in the post-anaesthesia care unit, compared with patients given spinal anaesthesia.
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Affiliation(s)
- Pasi M. Lehto
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Merja A. Vakkala
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Seppo Alahuhta
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Janne H. Liisanantti
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Tero H. J. Kortekangas
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Kaisu Hiltunen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Emma‐Sofia Nyman
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Timo I. Kaakinen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
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12
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Fanous SN, Saleh EG, Abd Elghafar EM, Ghobrial HZ. Randomized controlled trials between dorsal root ganglion thermal radiofrequency, pulsed radiofrequency and steroids for the management of intractable metastatic back pain in thoracic vertebral body. Br J Pain 2021; 15:270-281. [PMID: 34381612 PMCID: PMC8339942 DOI: 10.1177/2049463720942538] [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: 11/15/2022] Open
Abstract
BACKGROUND Bone metastasis is a complication of various cancers causing severe pain. The current modalities for the treatment of metastatic axial pain include pharmacological, surgical and vertebral augmentation techniques, each of which has its own challenges. OBJECTIVES To evaluate the effectiveness of pulsed radiofrequency (PRF), thermal radiofrequency (RF) and steroids on dorsal root ganglion (DRG) in patients with thoracic axial pain due to vertebral metastasis. METHODS In this randomized controlled prospective study, 140 patients were assessed for eligibility, of which only 69 fulfilled the criteria. Patients were randomly divided into three equal groups, PRF, RF and steroid. RESULTS During the assessment of pain using Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Opioid consumption using oral Morphine Equivalence (OME) and Analgesic Quantification Algorithm (AQA) - at baseline, 1 week, 1 month and 3 months - 81 patients were assessed for final eligibility, of which 12 were excluded before intervention due to drop-out. The remaining 69 were randomized (mean age: 53.87 ± 10.55, 55.78 ± 7.34 and 59.39 ± 13.72) for PRF, RF and steroid, respectively with no statistical difference. VAS% and ODI% decreased significantly at 3 months in RF group (p <0.001, 0.014, respectively), as did the AQA (p <0.027). Steroid group was the worst. DISCUSSION RF on DRG is the main stay for controlling intractable metastatic pain. PRF is a good alternative.
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Affiliation(s)
- Sherry Nabil Fanous
- Department of Anaesthesia, ICU and Pain
Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Emad Gerges Saleh
- Department of Anaesthesia, ICU and Pain
Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ekramy Mansour Abd Elghafar
- Department of Anaesthesia, ICU and Pain
Management, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Hossam Zarif Ghobrial
- Department of Anaesthesia, ICU and Pain
Management, National Cancer Institute, Cairo University, Cairo, Egypt
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13
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Yoon HG, Ahn YC, Oh D, Noh JM, Park SG, Nam H, Ju SG, Kwon D, Park S. Early Clinical Outcomes of Intensity Modulated Radiation Therapy/Intensity Modulated Proton Therapy Combination in Comparison with Intensity Modulated Radiation Therapy Alone in Oropharynx Cancer Patients. Cancers (Basel) 2021; 13:cancers13071549. [PMID: 33801766 PMCID: PMC8037748 DOI: 10.3390/cancers13071549] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Intensity-modulated proton therapy (IMPT) is expected to reduce toxicity more effectively than intensity-modulated radiation therapy (IMRT) in treating oropharynx cancer (OPC) patients. Because of long waiting before starting IMPT, authors began IMRT first and then determined whether to continue IMRT or to switch into IMPT at time of adaptive re-plan, based on the rival plan comparison in 148 OPC patients. Early clinical outcomes were analyzed and compared between IMRT alone and IMRT/IMPT combination groups through propensity score matching method. We found that, with comparable oncologic outcomes, more favorable acute toxicity profiles (mucositis and need for analgesic use) were achieved following IMRT/IMPT combination than IMRT alone. Abstract Purpose: To report the early clinical outcomes of combining intensity-modulated radiation therapy (IMRT) and intensity-modulated proton therapy (IMPT) in comparison with IMRT alone in treating oropharynx cancer (OPC) patients. Materials and Methods: The medical records of 148 OPC patients who underwent definitive radiotherapy (RT) with concurrent systemic therapy, from January 2016 till December 2019 at Samsung Medical Center, were retrospectively reviewed. During the 5.5 weeks’ RT course, the initial 16 (or 18) fractions were delivered by IMRT in all patients, and the subsequent 12 (or 10) fractions were either by IMRT in 81 patients (IMRT only) or by IMPT in 67 (IMRT/IMPT combination), respectively, based on comparison of adaptive re-plan profiles and availability of equipment. Propensity-score matching (PSM) was done on 76 patients (38 from each group) for comparative analyses. Results: With the median follow-up of 24.7 months, there was no significant difference in overall survival and progression free survival between groups, both before and after PSM. Before PSM, the IMRT/IMPT combination group experienced grade ≥ 3 acute toxicities less frequently: mucositis in 37.0% and 13.4% (p < 0.001); and analgesic quantification algorithm (AQA) in 37.0% and 19.4% (p = 0.019), respectively. The same trends were observed after PSM: mucositis in 39.5% and 15.8% (p = 0.021); and AQA in 47.4% and 21.1% (p = 0.016), respectively. In multivariate logistic regression, grade ≥ 3 mucositis was significantly less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.027 and 0.024, respectively). AQA score ≥ 3 was also less frequent in the IMRT/IMPT combination group, both before and after PSM (p = 0.085 and 0.018, respectively). Conclusions: In treating the OPC patients, with comparable early oncologic outcomes, more favorable acute toxicity profiles were achieved following IMRT/IMPT combination than IMRT alone.
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Affiliation(s)
- Han Gyul Yoon
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Yong Chan Ahn
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
- Correspondence:
| | - Dongryul Oh
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Jae Myoung Noh
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Seung Gyu Park
- Keimyung University Dongsan Medical Center, Department of Radiation Oncology, Keimyung University School of Medicine, Daegu 42601, Korea;
| | - Heerim Nam
- Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Korea;
| | - Sang Gyu Ju
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Dongyeol Kwon
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
| | - Seyjoon Park
- Samsung Medical Center, Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul 06351, Korea; (H.G.Y.); (D.O.); (J.M.N.); (S.G.J.); (D.K.); (S.P.)
- Yonsei Cancer Center, Department of Radiation Oncology, Yonsei University College of Medicine, Seoul 03722, Korea
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Khashab MA, Sanaei O, Rivory J, Eleftheriadis N, Chiu PWY, Shiwaku H, Ogihara K, Ismail A, Abusamaan MS, El Zein MH, Wong VW, Billioux VG, Kumbhari V, Kalloo AN, Ponchon T, Pioche M. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc 2020; 91:288-297.e7. [PMID: 31408652 DOI: 10.1016/j.gie.2019.07.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) has become the mainstay for the treatment of achalasia at many institutions around the world since its inception in 2008. POEM can be performed using either the anterior or posterior approach. The primary aim of this study was to compare the efficacy of the anterior and posterior approaches at 1 year after POEM. METHODS This is a single-blinded, randomized, noninferiority international clinical trial. Eligible participants were adult patients with a confirmed diagnosis of achalasia via high-resolution esophageal manometry. Patients were randomly allocated with a 1:1 ratio to receive POEM with anterior or posterior approach. The primary aim was to compare the rate of clinical success (Eckardt score <3) of anterior and posterior approaches at 1 year. RESULTS One hundred fifty patients were randomized to receive either anterior (n = 73) or posterior (n = 77) POEM. One hundred forty-eight patients received the POEM treatment, and 138 patients completed the 1-year follow-up and were included in the primary efficacy analysis. Technical success was achieved in 71 patients (97.3%) in the anterior group versus 77 patients (100%) in the posterior group (P = .23). The median (interquartile range) length of hospital stay after the procedure was 2 (1-3) days for both groups. Adverse events occurred in 15 patients (10%), 8 patients (11%) in the anterior group and 7 patients (9%) in the posterior group (P = .703). Clinical success was achieved in 90% of patients in the anterior group and 89% of patients in the posterior group. Abnormal esophageal acid exposure was detected in 29 of 59 patients (49%) and 25 of 60 patients (42%) in the anterior and posterior groups, respectively (P = .67). GERD questionnaire scores were also not significantly different between the study groups. In both groups, quality of life improved after POEM for all 36-Item Short-Form Health Survey measures and was similar between both groups. CONCLUSIONS Posterior myotomy during POEM was not inferior to anterior myotomy in terms of efficacy and safety in the treatment of patients with achalasia. (Clinical trial registration number: NCT02454335.).
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Jerome Rivory
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Nicholas Eleftheriadis
- Endoscopy Department, Gastroenterology Unit, Metropolitan Hospital Athens, Athens, and Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Philip Wai Yan Chiu
- Division of Upper GI & Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Kumi Ogihara
- Department of Gastroenterology and Hepatology, Nagazaki University Hospital, Nagazaki, Japan
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mohammed S Abusamaan
- Division of General Internal Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Mohamad H El Zein
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vivien W Wong
- Division of Upper GI & Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Veena G Billioux
- Bayview Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Thierry Ponchon
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Lyon, France
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15
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Henry D, von Moos R, Body JJ, Rider A, De Courcy J, Bhowmik D, Gatta F, Hechmati G, Qian Y. Bone-targeted agent treatment patterns and the impact of bone metastases on patients with advanced breast cancer in the United States. Curr Med Res Opin 2019; 35:375-381. [PMID: 30550358 DOI: 10.1080/03007995.2018.1558849] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Bone metastases are common among patients with advanced breast cancer, putting patients at increased risk of skeletal-related events (SREs). This study described impact of bone metastases, utilization of bone-targeted agents (BTAs) and physicians' decision processes for BTA use in advanced breast cancer. METHODS Data were collected using the Adelphi Breast Cancer Disease-Specific Programme in the United States. Physicians completed a detailed record for eligible patients (women ≥18 years, with stage IIIB-IV breast cancer). RESULTS Data available from 1276 patients with advanced breast cancer included 485 (38%) with bone metastases. Most (80%) reported pain at bone metastasis diagnosis; of those reporting pain, 55% reported moderate to severe pain. Among patients with bone metastasis, 69% received a BTA. Reasons for initiating BTAs were bone pain (32%) and an estimated high risk of SREs (25%). Reasons for not treating with BTAs were very recent diagnosis (37%), poor Karnofsky performance status (14%), perceived low risk of SREs (11%) and short life expectancy (11%). Zoledronic acid (48%) and denosumab (42%) were commonly used BTAs; the main reasons for initiating BTA treatment were long-term safety (28% and 32%, respectively) and efficacy in delaying SREs (15% and 31%, respectively). The analysis was not adjusted for age or other possible confounders. CONCLUSION Bone pain is a common and sometimes severe symptom of bone metastases in advanced breast cancer and a common reason for initiating BTA treatment. Safety and efficacy were the main factors considered by physicians when selecting BTAs.
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Affiliation(s)
- David Henry
- a Department of Oncology , Joan Karnell Cancer Center, Pennsylvania Hospital , Philadelphia , PA , USA
| | - Roger von Moos
- b Department of Oncology , Kantonsspital Graubünden , Chur , Switzerland
| | | | | | | | | | - Francesca Gatta
- f Global Health Economics, Amgen (Europe) GmbH , Zug , Switzerland
| | - Guy Hechmati
- e Global Health Economics, Amgen Inc. , Thousand Oaks , CA , USA
| | - Yi Qian
- e Global Health Economics, Amgen Inc. , Thousand Oaks , CA , USA
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16
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Body JJ, von Moos R, Rider A, Hallworth P, Bhowmik D, Gatta F, Hechmati G, Qian Y. A real-world study assessing the use of bone-targeted agents and their impact on bone metastases in patients with prostate cancer treated in clinical practice in Europe. J Bone Oncol 2019; 14:100212. [PMID: 30627511 PMCID: PMC6319023 DOI: 10.1016/j.jbo.2018.100212] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/10/2018] [Accepted: 12/14/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Bone metastases (BMs) are common in patients with prostate cancer and can lead to skeletal-related events (SREs), which are associated with increased pain and reduced quality of life (QoL). Bone-targeted agents (BTAs), such as zoledronic acid and denosumab, reduce the incidence of SREs and delay progression of bone pain. METHODS We evaluated the management of BMs and pain in six European countries (Belgium, France, Germany, Italy, Spain and the UK) using the Adelphi Prostate Cancer Disease Specific Programme. Patient-reported outcomes (PROs) were used to assess the impact of BMs on pain and QoL. RESULTS In total, 358 physicians completed Patient Record Forms, of whom 246 were oncologists and 112 were urologists. Data were collected on 3667 patients with prostate cancer, including 1971 with BMs and 551 with metastases at sites other than bone (non-BMs). PROs were assessed in 573 patients with BMs and 220 with non-BMs. Most patients with BMs (74%) received a BTA and 53% received treatment within 3 months of BM diagnosis. Patients treated by oncologists were more likely than those treated by urologists to receive a BTA (78% vs. 60%) and to have treatment initiated within 3 months of BM diagnosis (56% vs. 43%). For patients who did not receive a BTA, the main reasons for not treating were very recent BM diagnosis and a perceived low risk of bone complications. Data collected by physicians showed that most patients with BMs (97%) were taking analgesics, with 30% receiving strong opioids. Despite this, 70% were currently experiencing bone pain and 28% were experiencing moderate to severe pain. PRO pain measures showed that 70% of patients with BMs were experiencing moderate to extreme pain, suggesting a disparity between pain levels reported by physicians and by patients. CONCLUSIONS Although most patients with BMs receive a BTA, there remain a proportion of patients who are not receiving adequate treatment to prevent SREs or manage pain. Oncologists are more likely to adhere to clinical guidelines than urologists for the prescription of BTAs. Bone pain is common and undertreated. Increasing awareness of SRE prevention and bone pain management might improve patient care.
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Key Words
- AAP, abiraterone acetate with prednisone/prednisolone
- AQA, Analgesic Quantification Algorithm
- BMs, bone metastases
- BPI, Brief Pain Inventory
- BTA, bone-targeted agent
- Bone metastases
- Bone pain
- Bone-targeted agents
- DSP, Disease Specific Programme
- EQ-5D-3L, 5-dimension 3-level EuroQol questionnaire
- EU5, France, Germany, Italy, Spain and the UK
- FACT-P, Functional Assessment of Cancer Therapy – Prostate questionnaire
- ONJ, osteonecrosis of the jaw
- PRF, Patient Record Form
- PRO, patient-reported outcome
- PSCF, Patient Self-Completion Form
- QoL, quality of life
- SRE, skeletal-related event
- mCRPC, metastatic castration-resistant prostate cancer
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Affiliation(s)
- Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | | | | - Yi Qian
- Amgen Inc., Thousand Oaks, CA, USA
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17
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McKay RR, Bossé D, Gray KP, Michaelson MD, Krajewski K, Jacene HA, Walsh M, Bellmunt J, Pomerantz M, Harshman LC, Choueiri TK. Radium-223 Dichloride in Combination with Vascular Endothelial Growth Factor-Targeting Therapy in Advanced Renal Cell Carcinoma with Bone Metastases. Clin Cancer Res 2018; 24:4081-4088. [PMID: 29848570 PMCID: PMC6688176 DOI: 10.1158/1078-0432.ccr-17-3577] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 04/06/2018] [Accepted: 05/23/2018] [Indexed: 01/13/2023]
Abstract
Purpose: This study investigates the biologic activity of radium-223 with VEGF-targeted therapy in patients with advanced renal cell carcinoma (aRCC) and bone metastases.Patients and Methods: Fifteen treatment-naïve patients (n = 15) received pazopanib 800 mg orally once daily, and 15 previously treated patients received sorafenib 400 mg orally twice daily. Radium-223 55 kilobecquerel/kg was administered concurrently every 4 weeks for up to six infusions in both cohorts. The primary endpoint was decline in bone turnover markers (Procollagen I Intact N-Terminal, N-telopeptide, C-telopeptide, osteocalcin, and bone-specific alkaline phosphatase) compared with baseline. Secondary endpoints included safety, rate of symptomatic skeletal event (SSE) and time to first SSE, objective response rate, change in analgesic use, and quality of life. Exploratory analysis of tumor genomic alterations was performed.Results: Of the 30 patients enrolled, 83% had IMDC intermediate- or poor-risk disease, 33% had liver metastases, and 83% had a history of SSE prior to enrollment. No dose-limiting toxicity was observed. All bone turnover markers significantly declined from baseline at week 8 and 16. Forty percent of patients experienced treatment-related grade ≥3 adverse events. Response rates were 15% and 18% per RECIST v1.1 and bone response was 50% and 30% per MD Anderson criteria, in the pazopanib and sorafenib cohort, respectively. Median SSE-free interval was 5.8 months and not reached, respectively. Analgesic use remained stable over the study time.Conclusions: Radium-223 combined with VEGF-targeted therapy is biologically active and safe. Randomized-controlled trials are needed to define the role of radium-223 in aRCC with skeletal metastases. Clin Cancer Res; 24(17); 4081-8. ©2018 AACR.
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Affiliation(s)
- Rana R McKay
- Moores Cancer Center, UC San Diego Health, San Diego, California.
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Dominick Bossé
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Kathryn P Gray
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - M Dror Michaelson
- Genitourinary Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Katherine Krajewski
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Heather A Jacene
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Meghara Walsh
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joaquim Bellmunt
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Mark Pomerantz
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lauren C Harshman
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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18
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Arocho-Quinones EV, Kolimas A, LaViolette PS, Kaufman BA, Foy AB, Zwienenberg M, Lew SM. Split laminotomy versus conventional laminotomy: postoperative outcomes in pediatric patients. J Neurosurg Pediatr 2018; 21:615-625. [PMID: 29570034 DOI: 10.3171/2017.12.peds17368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Split laminotomy is a technique for accessing the spinal canal from the posterior midline that minimizes muscle dissection and bone removal. Benefits of this approach in minimizing postoperative pain and muscle atrophy in the adult population have been reported, but pediatric data are limited. Herein, the authors evaluate the benefits of the split laminotomy technique in pediatric patients. METHODS Data obtained in patients who underwent posterior spine surgery at Children's Hospital of Wisconsin for an intradural midline pathology between April 2008 and June 2015 were reviewed retrospectively. Each patient was assigned to one of two groups, the split-laminotomy or conventional-laminotomy group. The primary outcomes assessed were mean daily pain score, total opioid use over a period of 72 hours after surgery, and the degree of paraspinal muscle atrophy and fat infiltration found on short-term (1-4 months) and long-term (1-4 years) follow-up spine MRI studies. RESULTS A total of 117 patients underwent lumbar-level surgery (83 conventional laminotomy, 34 split laminotomy), and 8 patients underwent thoracic-level surgery (4 in each group). No significant difference in the mean daily pain scores between groups was found. The daily opioid use was significantly lower in the split-laminotomy group on postoperative day 0 (POD0) and POD1 but not on POD2 (p = 0.01, 0.01, and 0.10, respectively). The total opioid use over the 72-hour postoperative period was significantly lower in the split-laminotomy group (p = 0.0008). The fat/muscle ratio was significantly higher in both the short-term and long-term follow-up periods in the conventional-laminotomy group (p = 0.01 and 0.0002, respectively). The rate of change of paraspinal muscle fat infiltration was significantly lower in the split-laminotomy group than in the conventional-laminotomy group (p = 0.007). The incidence of complications was not significantly different between groups (p = 0.08). CONCLUSIONS This study was of the largest series reported thus far of pediatric patients who underwent split laminotomy and the only controlled study that has involved children. The authors' results reinforce the short-term benefit of split laminotomy in minimizing acute postoperative pain and long-term benefits of decreasing muscle atrophy and fatty degeneration, which are known to be associated with the development of chronic pain and spinal instability. Additional efforts for assessing long-term effects in the development of chronic pain, spinal instability, and spinal deformity are still necessary.
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Affiliation(s)
| | - Amie Kolimas
- 2Chicago College of Osteopathic Medicine, Downers Grove, Illinois
| | | | - Bruce A Kaufman
- Departments of1Neurosurgery and
- 4Department of Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; and
| | - Andrew B Foy
- Departments of1Neurosurgery and
- 4Department of Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; and
| | - Marike Zwienenberg
- 5Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California
| | - Sean M Lew
- Departments of1Neurosurgery and
- 4Department of Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; and
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von Moos R, Body JJ, Rider A, de Courcy J, Bhowmik D, Gatta F, Hechmati G, Qian Y. Bone-targeted agent treatment patterns and the impact of bone metastases on patients with advanced breast cancer in real-world practice in six European countries. J Bone Oncol 2018; 11:1-9. [PMID: 29892519 PMCID: PMC5993954 DOI: 10.1016/j.jbo.2017.11.004] [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] [Received: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Bone metastases (BMs) are common in patients with breast cancer and can lead to skeletal-related events (SREs), which are associated with increased pain and reduced quality of life (QoL). Bone-targeted agents (BTAs), like zoledronic acid and denosumab, reduce the incidence of SREs and delay progression of bone pain. MATERIALS AND METHODS We evaluated the management of BMs and pain in six European countries (Belgium, France, Germany, Italy, Spain, and UK) using the Adelphi Breast Cancer Disease Specific Programme, which included a physician survey and patient-reported outcomes (PROs) to assess the impact of BMs on pain and QoL. RESULTS 301 physicians completed patient record forms for 2984 patients with advanced breast cancer; 1408 with BMs and 1136 with metastases at sites other than bone (non-BMs). Most patients with BMs (88%) received a BTA, with 81% receiving treatment during 3 months following BM diagnosis. For those who did not receive a BTA, the main reasons given were: very recent BM diagnosis, perceived low risk of bone complications, and short life expectancy. Most patients with BMs (68%) were experiencing bone pain and, of these, 97% were taking analgesics (including 28% receiving strong opioids). Despite this, moderate to severe pain was reported in 20% of patients who were experiencing pain. PROs were assessed in 766 patients with advanced breast cancer (392 with BMs, 374 with non-BMs). Overall, patients with BMs reported worse pain and QoL outcomes than those with non-BMs, those not receiving a BTA reported worse pain. CONCLUSION Despite the large proportion of patients receiving BTAs in this study, some patients with BMs are still not receiving early treatment to prevent SREs or to manage pain. Improving physicians' understanding of the role of BTAs and the importance of early treatment following BM diagnosis has the potential to improve patient care.
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Key Words
- BMs, bone metastases
- BPI, Brief Pain Inventory
- BTA, bone-targeted agent
- Bone metastases
- Bone pain
- Bone-targeted agents
- CI, confidence interval
- DSP, Disease Specific Programme
- EQ-5D, 5-dimension (3-level) EuroQol questionnaire
- ER, estrogen receptor
- FACT-B, Functional Assessment of Cancer Therapy – Breast questionnaire
- HER2, human epidermal growth factor receptor 2
- ONJ, osteonecrosis of the jaw
- PRF, Patient Record Form
- PRO, patient-reported outcome
- PSCF, Patient Self-Completion Form
- QoL, quality of life
- SRE, Skeletal-related event
- ZA, zoledronic acid
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Affiliation(s)
- Roger von Moos
- Kantonsspital Graubünden, Loëstrasse 170, CH-7000 Chur, Switzerland
| | | | | | | | | | | | | | - Yi Qian
- Amgen Inc., Thousand Oaks, CA, USA
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Niskakangas M, Dahlbacka S, Liisanantti J, Vakkala M, Kaakinen T. Spinal or general anaesthesia for lower-limb amputation in peripheral artery disease - a retrospective cohort study. Acta Anaesthesiol Scand 2018; 62:226-233. [PMID: 29063607 DOI: 10.1111/aas.13019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 08/27/2017] [Accepted: 09/27/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The present study aimed to determine which method of anaesthesia (spinal anaesthesia or general anaesthesia) is better in reducing post-operative analgesic requirements in patients undergoing major limb amputation for lower-limb ischaemia. Another aim was to find out if anaesthesiologists use neuraxial anaesthesia in high-risk patients despite abnormal coagulation profile or use of anticoagulation. METHODS The study was a retrospective cohort study. All patients undergone above-the-knee amputation or below-the-knee amputation due to peripheral artery disease between 1996 and 2010 were reviewed to evaluate post-operative opioid consumption and complications. RESULTS A total of 434 amputations in 323 patients were included in the study. The number of surgical complications, the need for surgical revision and the number of intensive care unit admissions were significantly higher in the general anaesthesia group. The need for post-operative opioid medication was significantly lower in patients with above-the-knee amputation and spinal anaesthesia. The use of post-operative epidural analgesia did not reduce analgesic requirements. In the present study, there were patients who received neuraxial anaesthesia despite abnormal coagulation profile or uninterrupted warfarin or clopidogrel. There were no reported cases of spinal or epidural haematoma. CONCLUSION Patients with spinal anaesthesia had a lower rate of surgical complications, re-operations and intensive care unit admissions. Patients with above-the-knee amputation and spinal anaesthesia had a lesser need for opioid medication in the post-operative period than patients with general anaesthesia. Anaesthesiologists performed neuraxial anaesthesia and/or analgesia in high-risk patients despite abnormal coagulation profile or ongoing anticoagulation, but no adverse outcomes were reported.
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Affiliation(s)
- M. Niskakangas
- Department of Surgery; Oulu University Hospital; Oulu Finland
| | - S. Dahlbacka
- Department of Surgery; Oulu University Hospital; Oulu Finland
- Department of Vascular Surgery; Vaasa Central Hospital; Vaasa Finland
| | - J. Liisanantti
- Department of Anaesthesiology; Oulu University Hospital; Oulu Finland
- Division of Intensive Care Medicine; Oulu University Hospital; Oulu Finland
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine; Medical Research Center of Oulu University; Oulu University Hospital; Oulu Finland
| | - M. Vakkala
- Department of Anaesthesiology; Oulu University Hospital; Oulu Finland
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine; Medical Research Center of Oulu University; Oulu University Hospital; Oulu Finland
| | - T. Kaakinen
- Department of Anaesthesiology; Oulu University Hospital; Oulu Finland
- Research Group of Surgery, Anesthesiology and Intensive Care Medicine; Medical Research Center of Oulu University; Oulu University Hospital; Oulu Finland
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Chin-Hung Chen V, Yang YH, Chen PY, Yang JT, Chen CPC, Chen CJ, Lu ML, Lee Y, McIntyre RS, Huang YC. Factors affecting lumbar surgery outcome: A nation-wide, population-based retrospective study. J Affect Disord 2017; 222:98-102. [PMID: 28688267 DOI: 10.1016/j.jad.2017.06.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 05/05/2017] [Accepted: 06/26/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Lower back pain is a very common symptom and treatment strategies vary according the severity and duration of illness. Surgical approaches are becoming increasingly popular with the advent of new and less invasive technologies; however, treatment outcomes are not yet well established on a population-based level. Taiwan's National Health Insurance Research Database (NHIRD) is longitudinal and includes 98% of the population since its inception in 1995. The database includes the ICD 9.0 codes (International Classification of Diseases) of all patients with lower back pain and lumbar surgery; furthermore, all the prescriptions. METHODS As part of a population-based cohort study of one million participants randomly selected from the NHIRD, we analyzed changes in prescription of analgesics 1 year before and 1 year after lumbar surgery; comorbidities, such as diabetes, asthma, osteoporosis, arthritis, depression and anxiety were also analyzed as covariates. A total of 3916 cases were enrolled in final analysis. RESULTS Post-operatively, the defined daily dosage (DDD) of analgesics decreased from a median DDD of 50.0 to a median of 14.2. In a multivariate model analysis, female, older age, anxiety and asthma were the significant factors for unfavorable outcome (defined by dosage of analgesics decreased less than 50% after surgery). CONCLUSIONS The analgesics significantly decreased for patients received lumbar surgeries, implying the decreased of pain. In addition, co-morbidity factors were identified by the failure for analgesics reduction, such as female, older age, anxiety and asthma. For patients with lower back pain, these factors should be considered before receiving lumbar surgeries.
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Affiliation(s)
- Vincent Chin-Hung Chen
- Department of Psychiatry, Chang Gung Memorial Hospital, Chiayi branch, Taiwan; Department of Medicine, Chang Gung University, Taiwan
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi branch, Taiwan; Center of Excellence for Chang Gung Research Datalink, Chang Gung Memorial Hospital, Chiayi, Taiwan; Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan; School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pin-Yuan Chen
- Department of Medicine, Chang Gung University, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung branch, Taiwan
| | - Jen-Tsung Yang
- Department of Medicine, Chang Gung University, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital, Chiayi branch, Taiwan
| | - Carl P C Chen
- Department of Medicine, Chang Gung University, Taiwan; Department of Rehabilitation, Chang Gung Memorial Hospital, Linkou brain, Taiwan
| | - Chi-Jen Chen
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Mong Liang Lu
- Department of Psychiatry, Wan Fang Hospital & School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yena Lee
- Mood Disorder Psychopharmacology Unit, University Health Network, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, University of Toronto, Toronto, Canada; Institute of Medical Science, University of Toronto, Toronto, Canada; Department of Psychiatry and Pharmacology, University of Toronto, Canada
| | - Yin-Cheng Huang
- Department of Medicine, Chang Gung University, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital, Keelung branch, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou branch, Taiwan.
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22
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Lucchesi M, Lanzetta G, Antonuzzo A, Rozzi A, Sardi I, Favre C, Ripamonti CI, Santini D, Armento G. Developing drugs in cancer-related bone pain. Crit Rev Oncol Hematol 2017; 119:66-74. [PMID: 28893462 DOI: 10.1016/j.critrevonc.2017.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/13/2017] [Accepted: 08/19/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Cancer-related bone pain is a frequent and important key problem for metastatic patients that may reduce quality of life, with related limitations in daily activities and morbidity. Often traditional approach to pain may fail given the complex pathophysiology of this phenomenon. METHODS The aim of this review is to describe promising therapies for cancer-related bone pain, from the pathophysiology to the clinical trials currently ongoing. Moreover, any new evidence for better approach to cancer-related bone pain with the traditional drugs is also considered. CONCLUSIONS In clinical practice opioids remain the most important pharmacologic treatment for severe pain related to bone cancer. Regard developing drugs, anti-NGF and anti-TrkA are the most investigated new drug in this setting, but a future role in clinical practice is still uncertain.
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Affiliation(s)
- Maurizio Lucchesi
- Thoracic Cancer Centre, Pulmonology Unit, University Hospital of Pisa, Pisa, Italy; Department of Pediatric Oncology and Hematology, Anna Meyer Children's University Hospital, Florence, Italy.
| | - Gaetano Lanzetta
- Medical Oncology Unit, IRCCS Neuromed, Pozzilli, Italy; Medical Oncology Unit, Italian Neuro-Traumatology Institute, Grottaferrata, Italy.
| | - Andrea Antonuzzo
- Medical Oncology Unit 1 SSN, Pisa University Hospital, Pisa, Italy.
| | - Antonio Rozzi
- Medical Oncology Unit, Italian Neuro-Traumatology Institute, Grottaferrata, Italy.
| | - Iacopo Sardi
- Department of Pediatric Oncology and Hematology, Anna Meyer Children's University Hospital, Florence, Italy.
| | - Claudio Favre
- Department of Pediatric Oncology and Hematology, Anna Meyer Children's University Hospital, Florence, Italy.
| | - Carla Ida Ripamonti
- Supportive Care in Cancer Unit, IRCCS National Cancer Institute, Milan, Italy.
| | - Daniele Santini
- Medical Oncology Unit, Campus Biomedico University Hospital, Rome, Italy.
| | - Grazia Armento
- Medical Oncology Unit, Campus Biomedico University Hospital, Rome, Italy.
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Kao SC, Tsai HI, Cheng CW, Lin TW, Chen CC, Lin CS. The association between frequent alcohol drinking and opioid consumption after abdominal surgery: A retrospective analysis. PLoS One 2017; 12:e0171275. [PMID: 28301483 PMCID: PMC5354251 DOI: 10.1371/journal.pone.0171275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 01/17/2017] [Indexed: 01/29/2023] Open
Abstract
Aims It is perceived that patients with a history of frequent alcohol consumption require more opioids for postoperative pain control and experience less postoperative nausea and vomiting than patients without such a history. However, there is scarce evidence supporting this notion. The aim of this study was to assess association between frequent alcohol consumption and opioid requirement for postoperative pain control and occurrence of postoperative nausea and vomiting. Methods The medical records for 4143 patients using intravenous patient-control analgesia with opioids after abdominal surgery between January 2010 and September 2013 were obtained, and associations were sought between the cumulative opioid consumption (in intravenous morphine equivalence) per body weight (mg/kg) in the first 2 days after abdominal operation and several demographic and clinical variables by multiple regression analysis. The association between the occurrence of postoperative nausea and vomiting and several demographic and clinical variables was also sought by multiple logistic regression analysis. Results Frequent alcohol drinking, among other previously reported factors, was associated with increased opioid consumption for postoperative pain control (p < 0.001). The estimate effect of frequent alcohol drinking was 0.117 mg/kg. Frequent alcohol drinking was also associated with decreased risks of postoperative nausea (odds ratio = 0.59, p = 0.003) and vomiting (odds ratio = 0.49, p = 0.026). Conclusions Frequent alcohol drinking was associated with increased opioid consumption for postoperative pain control and decreased risks of postoperative nausea and vomiting after abdominal surgery.
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Affiliation(s)
- Sheng-Chin Kao
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei City, Taiwan
- School of Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Hsin-I Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Chih-Wen Cheng
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou, Taoyuan City, Taiwan
| | - Ta-Wei Lin
- Department of Anesthesiology, National Yang-Ming University Hospital, Yilan City, Yilan County, Taiwan
| | - Chien-Chuan Chen
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Chia-Shiang Lin
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei City, Taiwan
- * E-mail:
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Abstract
This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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25
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Improving quality of life in patients with advanced cancer: Targeting metastatic bone pain. Eur J Cancer 2017; 71:80-94. [DOI: 10.1016/j.ejca.2016.10.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/22/2016] [Indexed: 12/17/2022]
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Morad AH, Tamargo RJ, Gottschalk A. The Longitudinal Course of Pain and Analgesic Therapy Following Aneurysmal Subarachnoid Hemorrhage: A Cohort Study. Headache 2016; 56:1617-1625. [PMID: 27704534 DOI: 10.1111/head.12908] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the duration, intensity, location, and usual treatment of pain throughout hospitalization following subarachnoid hemorrhage. BACKGROUND Headache following subarachnoid hemorrhage can be sudden and severe. Little is known about the longitudinal course of headache or its analgesic therapy following the initial diagnosis of subarachnoid hemorrhage. METHODS A prospectively maintained database of 564 patients diagnosed with cerebral aneurysms collected from 10/2009 to 2/2013 was searched for conscious patients with subarachnoid hemorrhage. Available electronic records were queried for pain scores (0-10/10), location, and analgesic consumption. RESULTS Forty-six adults with subarachnoid hemorrhage met eligibility criteria for inclusion. Mean [CI 95] daily pain was 3.8 [3.2, 4.4] and maximal daily pain was 5.8 [5.1, 6.6]. Eighty-nine percent of patients reported severe pain of 7-10/10, and 63% of patients reported 10/10 pain at some point during hospitalization. While mean [CI 95] pain declined over the course of hospital stay at a rate of 0.06 [0.04, 0.07] units/day (P < .001), mean [CI 95] maximal daily pain changed at a rate of -0.03 [-0.06, 0.01] units/day, which is not significantly different than zero (P = .15). Pain was located primarily in the head in 76% of subjects but pain in the back, neck, limbs, and eyes was also reported. All patients received oral acetaminophen with increasing daily doses. All but three patients, received opioids, most commonly intravenous fentanyl and oral oxycodone. The mean [95 CI] intravenous morphine equivalent dose of opioids consumed was 15.7 [10.3, 21.1] mg/day and changed at a rate of -0.11 [-0.37, 0.15] mg/day which is not significantly different than zero (P = .40). CONCLUSION Despite steady consumption of analgesics, the pain reported by conscious patients while recovering from subarachnoid hemorrhage in the hospital is often severe and persists throughout hospitalization.
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Affiliation(s)
- Athir H Morad
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Allan Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Hockett MM, Hembrador S, Lee A. Continuous Quadratus Lumborum Block for Postoperative Pain in Total Hip Arthroplasty. ACTA ACUST UNITED AC 2016; 7:129-31. [DOI: 10.1213/xaa.0000000000000363] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Leegwater NC, Nolte PA, de Korte N, Heetveld MJ, Kalisvaart KJ, Schönhuth CP, Pijnenburg B, Burger BJ, Ponsen KJ, Bloemers FW, Maier AB, van Royen BJ. The efficacy of continuous-flow cryo and cyclic compression therapy after hip fracture surgery on postoperative pain: design of a prospective, open-label, parallel, multicenter, randomized controlled, clinical trial. BMC Musculoskelet Disord 2016; 17:153. [PMID: 27059990 PMCID: PMC4826534 DOI: 10.1186/s12891-016-1000-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 03/30/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The number of hip fractures and resulting post-surgical outcome are a major public health concern and the incidence is expected to increase significantly. The acute recovery phase after hip fracture surgery in elder patients is often complicated by severe pain, high morphine consumption, perioperative blood loss with subsequent transfusion and delirium. Postoperative continuous-flow cryocompression therapy is suggested to minimize these complications and to attenuate the inflammatory reaction that the traumatic fracture and subsequent surgical trauma encompass. Based on a pilot study in patients undergoing total hip arthroplasty for osteoarthritis, it is anticipated that patients treated with continuous-flow cryocompression therapy will have less pain, less morphine consumption and lower decrease of postoperative hemoglobin levels. These factors are associated with a shorter hospital stay and better long-term (functional) outcome. METHODS/DESIGN One hundred and sixty patients with an intra or extracapsular hip fracture scheduled for internal fixation (intramedullary hip nail, dynamic hip screw or cannulated screws) or prosthesis surgery (total hip or hemiarthroplasty) will be included in this prospective, open-label, parallel, multicenter, randomized controlled, clinical superiority trial. Patients will be allocated to two treatment arms: group 'A' will be treated with continuous-flow cryocompression therapy and compared to group 'B' that will receive standard care. Routine use of drains and/or compressive bandages is allowed in both groups. The primary objective of this study is to compare acute pain the first 72 h postoperative, measured with numeric rating scale for pain. Secondary objectives are: (non-) morphine analgesic use; adjusted postoperative hemoglobin level; transfusion incidence; incidence, duration and severity of delirium and use of psychotropic medication; length of stay; location and duration of rehabilitation; functional outcome; short-term patient-reported health outcome; general and cryotherapy related complications and feasibility. DISCUSSION This is the first randomized controlled trial that will assess the analgesic efficiacy of continuous-flow cryocompression therapy in the acute recovery phase after hip fracture surgery. TRIAL REGISTRATION www.trialregister.nl, NTR4152 (23(rd) of August 2013).
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Affiliation(s)
- Nick C. Leegwater
- />Department of Orthopedics, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Peter A. Nolte
- />Department of Orthopedics, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Niels de Korte
- />Department of Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | | | | | - Casper P. Schönhuth
- />Department of Orthopedics, VU University Medical Center, Amsterdam, The Netherlands
| | - Bas Pijnenburg
- />Department of Orthopedics, Amstelland Hospital, Amstelveen, The Netherlands
| | - Bart J. Burger
- />Department of Orthopedics, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Kees-Jan Ponsen
- />Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Frank W. Bloemers
- />Department of Surgery, Section of Traumasurgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Andrea B. Maier
- />Department of Internal Medicine, Section of Gerontology and Geriatrics, VU University Medical Center, Amsterdam, The Netherlands
| | - Barend J. van Royen
- />Department of Orthopedics, VU University Medical Center, Amsterdam, The Netherlands
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von Moos R, Body JJ, Egerdie B, Stopeck A, Brown J, Fallowfield L, Patrick DL, Cleeland C, Damyanov D, Palazzo FS, Marx G, Zhou Y, Braun A, Balakumaran A, Qian Y. Pain and analgesic use associated with skeletal-related events in patients with advanced cancer and bone metastases. Support Care Cancer 2016; 24:1327-37. [PMID: 26329397 PMCID: PMC4729787 DOI: 10.1007/s00520-015-2908-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 08/16/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Bone metastases secondary to solid tumors increase the risk of skeletal-related events (SREs), including the occurrence of pathological fracture (PF), radiation to bone (RB), surgery to bone (SB), and spinal cord compression (SCC). The aim of this study was to evaluate the impact of SREs on patients' pain, analgesic use, and pain interference with daily functioning. METHODS Data were combined from patients with solid tumors and bone metastases who received denosumab or zoledronic acid across three identically designed phase 3 trials (N = 5543). Pain severity (worst pain) and pain interference were assessed using the Brief Pain Inventory at baseline and each monthly visit. Analgesic use was quantified using the Analgesic Quantification Algorithm. RESULTS The proportion of patients with moderate/severe pain and strong opioid use generally increased in the 6 months preceding an SRE and remained elevated, while they remained relatively consistent over time in patients without an SRE. Regression analysis indicated that all SRE types were significantly associated with an increased risk of progression to moderate/severe pain and strong opioid use. PF, RB, and SCC were associated with significantly greater risk of pain interference overall. Results were similar for pain interference with emotional well-being. All SRE types were associated with significantly greater risk of pain interference with physical function. CONCLUSIONS SREs are associated with increased pain and analgesic use in patients with bone metastases. Treatments that prevent SREs may decrease pain and the need for opioid analgesics and reduce the impact of pain on daily functioning.
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Affiliation(s)
- Roger von Moos
- Kantonsspital Graubünden, Loëstrasse 170, CH-7000, Chur, Switzerland.
| | | | | | - Alison Stopeck
- Arizona Cancer Center, University of Arizona, Tucson, AZ, USA
| | - Janet Brown
- Experimental Cancer Medicine Centre, Weston Park Hospital, University of Sheffield, Sheffield, UK
| | | | | | - Charles Cleeland
- University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Danail Damyanov
- National Hospital for Treatment in Oncology, Sofia, Bulgaria
| | | | - Gavin Marx
- Sydney Adventist Hospital, Wahroonga, Sydney, Australia
| | | | | | | | - Yi Qian
- Amgen, Inc., Thousand Oaks, CA, USA
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Pain Control after Total Knee Arthroplasty: Comparing Intra-Articular Local Anesthetic Injection with Femoral Nerve Block. BIOMED RESEARCH INTERNATIONAL 2015; 2015:649140. [PMID: 26064937 PMCID: PMC4433655 DOI: 10.1155/2015/649140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 04/01/2015] [Accepted: 04/01/2015] [Indexed: 12/17/2022]
Abstract
Background. Direct intra-articular injection of low doses of local anesthetic (IALA) after closure of the joint capsule remains controversial for pain control after total knee arthroplasty (TKA). Methods. A retrospective study comparing patients receiving IALA with high doses (0.5% bupivacaine 60 mL) of local anesthetics or FNB in addition to intravenous patient-controlled analgesia with opioids for pain management after TKA was conducted. The primary end point was to compare the analgesic efficacy and early ambulation between the two groups. Results. No significant differences between the two groups in pain intensity, cumulative opioid consumption, incidences of opioid-related side effects, the time interval from the end of operation to the first time the patient could walk assisted with a walker postoperatively, and postoperative hospital stay were identified. Three patients in the IALA group but none in the FNB group walked within 12 hours after the end of operation. Summary. IALA with high doses of local anesthetics provides comparable analgesic efficacy as single-shot FNB after TKA and might be associated with earlier ambulation than FNB postoperatively.
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31
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Pain outcomes in patients with bone metastases from advanced cancer: assessment and management with bone-targeting agents. Support Care Cancer 2014; 23:1157-68. [DOI: 10.1007/s00520-014-2525-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/14/2014] [Indexed: 12/25/2022]
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Martin-Broto J, Cleeland CS, Glare PA, Engellau J, Skubitz KM, Blum RH, Ganjoo KN, Staddon A, Dominkus M, Feng A, Qian Y, Braun A, Jacobs I, Chung K, Atchison C. Effects of denosumab on pain and analgesic use in giant cell tumor of bone: interim results from a phase II study. Acta Oncol 2014; 53:1173-9. [PMID: 24834795 DOI: 10.3109/0284186x.2014.910313] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Giant cell tumor of bone (GCTB) is an aggressive primary osteolytic tumor. GCTB often involves the epiphysis, usually causing substantial pain and functional disability. Denosumab, a fully human monoclonal antibody against receptor activator of nuclear factor κΒ ligand (RANKL), is an effective treatment option for patients with advanced GCTB. This analysis of data from an ongoing, open-label study describes denosumab's effects on pain and analgesic use in patients with GCTB. MATERIAL AND METHODS Patients with unresectable disease (e.g. sacral or spinal GCTB, or multiple lesions including pulmonary metastases) were enrolled into Cohort 1 (N = 170), and patients with resectable disease whose planned surgery was associated with severe morbidity (e.g. joint resection, limb amputation, or hemipelvectomy) were enrolled into Cohort 2 (N = 101). Patients received denosumab (120 mg) subcutaneously every four weeks, with additional doses on study days 8 and 15. Patients assessed worst pain severity with the Brief Pain Inventory - Short Form (BPI-SF) at baseline, at each visit for the first six months, and every three months thereafter. RESULTS Clinically relevant pain improvement was reported by 29% of patients in Cohort 1 and 35% in Cohort 2 during week 1 and by ≥ 50% of patients in each cohort at each study visit from months 2-30. Median time to clinically relevant improvement was 30 (95% CI 16, 57) days in Cohort 1 and 15 (95% CI 15, 29) days in Cohort 2. Results in patients with moderate/severe pain at baseline were similar. Fewer than 30% of patients in Cohort 1 and 10% in Cohort 2 experienced clinically relevant pain worsening at any visit through 27 months. Most patients had no/low analgesic use during the study. CONCLUSION Most patients treated with denosumab experienced clinically relevant decreases in pain within two months.
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Affiliation(s)
- Javier Martin-Broto
- Sarcoma and Melanoma Units, Son Espases Hospital , Palma de Mallorca , Spain
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