Management of pain and spinal cord compression in patients with advanced cancer. ACP-ASIM End-of-life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine

Benefits of Spiritual and Religious Support in the Pain Management of Cancer Patients: A Literature Scoping Review

Pain is one of the main symptoms of cancer and the most difficult to control due to its complexity as it can involve physical, psychological, social, and spiritual aspects. We proposed to summarize the scientific knowledge already published related to the influence of spirituality on pain therapy in cancer patients. Articles were searched in PubMed, SciELO, SciFinder, PsycInfo, and ScienceDirect databases using the following descriptors: "Spirituality," "Religion," "Religion," "Chronic Pain," "Pain Management" and "Cancer." A total of 68 articles were included and discussed. Most articles dealt with the influence of spirituality in palliative care, focussed on patient quality, and highlighted the importance of integrative oncology. Although few studies associated spirituality with chronic pain, most articles reported that spirituality could confer greater pain control.

The Influence of Physical and Psychosocial Factors on Disruptive Pain Among Seriously Ill Home Care Patients

OBJECTIVES

To estimate the prevalence and correlates of disruptive pain in a sample of seriously ill home care patients in the Canadian province of Ontario.

METHODS

The design was a cross-sectional analysis of secondary data from 2757 patients aged 65+.

RESULTS

Overall, 69.0% (n = 1902) had any level of pain and 41.6% (n = 1146) indicated that their pain disrupted their usual activities. In the univariate analysis of demographics, the risk of disruptive pain decreased significantly with increasing age ( P < .0001) and was significantly less common among men ( P = .0015). Multivariate analysis showed that unsteady gait (relative risk [RR] = 1.37; 95% confidence interval [CI], 1.18-1.59), arthritis (RR = 1.35; 95% CI, 1.23-1.49), symptoms of depression (RR = 1.24; 95% CI, 1.13-1.37), and declines in social activity that the patient rated as distressing (RR = 1.19; 95% CI, 1.08-1.31) were independently associated with disruptive pain.

CONCLUSION

Disruptive pain is highly prevalent in this group, and the key factors associated with this outcome represent physical as well as psychosocial domain areas.

Identifying oncological emergencies

Prompt identification and treatment of life-threatening oncological conditions is of utmost importance and should always be included in the differential diagnosis. Oncological emergencies can have a myriad of presentations ranging from mechanical obstruction due to tumor growth to metabolic conditions due to abnormal secretions from the tumor. Notably, hematologic and infectious conditions may complicate the presentation of oncological emergencies. Advanced testing and imaging is generally required to recognize these serious presentations of common malignancies. Early diagnosis and treatment of these conditions can significantly affect the patient's clinical outcome.

Daily pain and functional decline among old-old adults living in the community: results from the ilSIRENTE Study

Few studies have assessed the impact of pain on physical function among old-old subjects. The aim of the present observational study was to evaluate the association between presence of daily pain and incident disability in elderly subjects aged 80 years or older living in the community. We used data from the "Invecchiamento e Longevità nel Sirente" (ilSIRENTE) project, a two-year longitudinal study enrolling subjects aged 80 years or older. Daily pain was defined as any type of pain or discomfort in any part of the body manifested every day over the seven days preceding the baseline assessment. Disability in performing activities of daily living (ADLs) was defined as the need of assistance in one or more of the following ADLs: eating, dressing, transferring, mobility in bed, personal hygiene, and toileting. The mean age of 204 subjects participating to this study was 84.3 years (standard deviation [SD]: 3.8), and 135 (SD: 66.1%) were women. Of the total sample, 103 subjects (50.4%) presented with daily pain. After a two-year follow-up, 25 of 103 (24.2%) participants with daily pain and 14 of 101 (13.9%) without daily pain developed disability. After adjusting for potential confounders, presence of daily pain was associated with an increased risk of disability, but this association did not reach statistical significance (hazard ratio [HR]: 1.87; 95% confidence interval [CI]: 0.92-4.26). The risk of disability increased with pain severity. Compared with subjects without daily pain, the risk of incident disability was higher for participants with mild pain (HR: 1.35; 95% CI: 0.65-3.28) and significantly higher for those with moderate to severe pain (HR: 6.94; 95% CI: 2.00-23.01). In conclusion, among very old subjects living in the community, moderate to severe daily pain is associated with a significant increased risk of disability, irrespective of potential confounders.

Symptomatic thoracic spinal cord compression caused by postsurgical pseudomeningocele

We report the first case of symptomatic thoracic spinal cord compression caused by postsurgical pseudomeningocele. A 49-year-old man sought treatment for progressive loss of strength in the lower extremities ten months after full neurological recovery for a thoracic (T11) intradural-extramedullary schwannoma. Magnetic resonance imaging revealed a postsurgical thoracic (T11-T12) pseudomeningocele. The surgical approach showed an inadequate dural closure with spontaneous cerebrospinal fluid fistula. The defect was sealed with suture, muscle and biological glue covering. The patient had a good recovery. Pseudomeningocele must take part of the differential diagnosis of myelopathy after thoracic spine surgery.

Morphine attenuates microvascular hyperpermeability via a protein kinase A-dependent pathway

BACKGROUND

A recently published study from our laboratory demonstrated that morphine sulfate (MS) attenuates microvascular hyperpermeability after hemorrhagic shock in rats. MS binds to the mu receptors located on the surface of endothelial cells. Activation of the endothelial cell mu receptors has been shown by several investigators to stimulate adenylate cyclase. We hypothesize that MS binding to the mu receptor on endothelial cells increases cyclic adenosine monophosphate via adenylate cyclase activation. Cyclic adenosine monophosphate inhibits the phosphoinositide/MAP kinase hyperpermeability pathway via the protein kinase A (PKA)-dependent inhibition of Raf-1.

METHODS

Studies were conducted in five groups of urethane-anesthetized Sprague-Dawley rats: Group 1--control group, Group 2--a non-receptor-blocking adenylate cyclase inhibitor: SQ22536, at 100 microg/kg (n = 5), Group 3--a PKA inhibitor: H89, at 10 microg/kg, Group 4--a morphine sulfate (10 microg/kg) and PKA inhibitor group, and Group 5--an adenylate cyclase inhibited and morphine (10 microg/kg) group. Intravital microscopy in mesenteric postcapillary venules and rat lung microvascular endothelial cell monolayers were used to measure permeability.

RESULTS

Adenylate cyclase and PKA inhibition resulted in vascular hyperpermeability.

CONCLUSION

Our data demonstrated an increase in vascular hyperpermeability after inhibition of adenylate cyclase via SQ22536, a nonreceptor inhibitor. This increase in hyperpermeability was attenuated when treated with MS. Morphine did not attenuate hyperpermeability after blockage following PKA with H89 suggesting the action of MS is upstream of PKA and PKA dependent.

Spinal cord compression secondary to bone metastases from hepatocellular carcinoma

Bone metastases are rare in primary hepatocellular carcinoma (HCC). Spinal cord compression (SCC) due to bone metastases occur commonly in patients with lung and breast carcinomas, and metastatic HCC is an unusual cause of SCC. Spinal cord compression is an oncologic emergency and treatment delays can lead to irreversible consequences. Thus, the awareness that SCC could be a potential complication of bone metastases due to HCC is of significance in initiation of early treatment that can improve the quality of life and survival of the patients, if diagnosed earlier. This paper describes four cases of primary HCC with varied manifestations of SCC due to bone metastases. The first patient presented primarily with the symptoms of bone pains corresponding to the bone metastases sites rather than symptoms of associated hepatic pathology and eventually developed SCC. The second patient, diagnosed as having HCC, developed extradural SCC leading to paraplegia during the course of illness, for which he underwent emergency laminectomy with posterior fixation. The third patient developed SCC soon after the primary diagnosis and had to undergo emergency laminectomy. Post laminectomy he had good neurological recovery. The Fourth patient presented primarily with radicular pains rather than frank paraplegia as the first manifestation of SCC.

Morphine Sulfate Attenuates Hemorrhagic Shock- Induced Hyperpermeability

Morphine sulfate is often administered for patients requiring surgical intervention for the control of hemorrhage. Recent data implicate morphine as an immune modulator that affects white blood cells and increases infection rates. In addition, morphine releases histamine, an inflammatory mediator that increases microvascular permeability. Both of these actions of morphine could aggravate the inflammatory progress after hemorrhagic shock. In this study, we evaluated the role of morphine sulfate on microvascular permeability and its effects on leukocyte adherence after hemorrhagic shock. After a control period, blood was withdrawn to reduce the mean arterial blood pressure to 40 mm Hg for 1 h in urethane-anesthetized Sprague-Dawley rats. Mesenteric postcapillary venules in a transilluminated segment of small intestine were examined to quantify changes in permeability and leukocyte adherence. The rats received an IV injection of fluorescein isothiocyanate-bovine albumin during the control period. The fluorescent light intensity emitted from the fluorescein isothiocyanate-bovine albumin was recorded with digital microscopy within the lumen of the microvasculature and compared with the intensity of light in the extraluminal space over time. These images were downloaded to a computerized image analysis program that quantitates changes in light intensity. This change in light intensity represents albumin extravasation. In addition, bright-field images were recorded on compact disk for playback to determine leukocyte adherence. Leukocytes stationary for more than 30 s or longer in a 100-micron segment of venule was considered adherent. Our results demonstrated a marked increase in fluorescein isothiocyanate-bovine albumin leakage into the extravascular space after hemorrhagic shock. Hemorrhagic shock was also associated with an increase in leukocytes adhering to the postcapillary venular endothelium. Morphine sulfate 10 microg/kg given before the shock period, attenuated both the hyperpermeability (P < 0.05) and the increase in leukocyte adherence (P < 0.05) after hemorrhagic shock. These results suggest that instead of aggravating the inflammatory response after hemorrhagic shock, morphine may provide protection to the microvasculature.

Drugs used to alleviate symptoms with life shortening as a possible side effect: end-of-life care in six European countries

We investigated the drugs used in the alleviation of pain and symptoms (APS) with a possible life-shortening side effect in six European countries' end-of-life care. We sent mail questionnaires to physicians who signed a representative sample of death certificates in each country. APS with a possible life-shortening effect occurred from 19% of all deaths in Italy to 26% in Denmark. Physicians usually administered opioids (from 76% of APS cases in Italy to 96% in The Netherlands), but the type of opioids and administration practice differed markedly between countries. The doses of opioids given in the last 24 hours also varied significantly and were usually lower than 300 mg oral morphine equivalent (from 83% of cases in Belgium to 93% in Sweden). The highly variable results bring into question whether existing guidelines for pain relief were applied appropriately and to what extent unfounded concerns about the possible life-shortening effect of opioids resulted in less than optimal symptom management in end-of-life care.

Pain and its relation to depressive symptoms in frail older people living in the community: an observational study

The association of pain and depression represents an important health problem that is correlated with high rates of disability, morbidity, greater consumption of health care resources, and socioeconomic difficulties. Understanding the interaction between pain and depression is an important issue in light of the fact that physicians frequently fail to accurately assess and diagnose pain symptoms, and that elderly patients suffering from pain are particularly likely to receive inaccurate treatments. The aim of the present study was to describe the prevalence of pain and to investigate the association between pain and depressive symptoms in a representative sample of frail elderly people living in the community (n=5,372). The results show that more than 15% and 40% of elderly patients experienced pain less than daily and daily, respectively. The average score on the depression scale was significantly lower in patients without pain (2.5+/-2.5) than patients with less than daily and daily pain (3.2+/-2.5 and 3.6+/-2.5, respectively) (P<0.001). Without substantial differences between men and women, the rate of each depressive symptom was significantly and progressively higher among patients suffering less than daily and daily pain compared to those without pain. In conclusion, this study provides evidence from a large sample of frail elderly people that individuals suffering pain present an elevated risk to experience depressive symptoms. Treatment models that put together the assessment and the treatment of both pain and depression are indispensable for better outcomes.

Comparison of resource utilization by patients treated with transdermal fentanyl and long-acting oral opioids for nonmalignant pain

OBJECTIVE

To quantify resource utilization and costs incurred for patients who received transdermal fentanyl as their first long-acting analgesic for non-malignant pain, and to compare these with utilization and costs for similar patients dispensed other long-acting oral opioids.

DESIGN

A retrospective matched cohort study using medical claims data from a large New England Insurer.

PATIENTS

We identified 478 patients without cancer who received transdermal fentanyl during 1995-1998. We selected patients who had no previous long-acting opioid dispensings and were enrolled during the 180 days before and 30 days following the initial dispensing. We used propensity scores to identify a matched comparison group of 478 long-acting oral opioid users.

RESULTS

Transdermal fentanyl and matched long-acting oral opioid users incurred identical median costs for outpatient medical services and prescriptions during 2 years of follow-up. A larger proportion of transdermal fentanyl patients were still taking their initial opioid analgesic at the end of the 2-year follow-up than were patients initially taking other long-acting opioids. Use of short-acting opioids tapered off more slowly among transdermal fentanyl patients than among long-acting opioid patients. In the first 6 months, the transdermal fentanyl patients had more hospital discharges than the long-acting oral opioid patients, but this difference appeared to reflect preexisting conditions.

CONCLUSIONS

Users of fentanyl transdermal system and other long-acting opioids experienced essentially identical evolution of health services utilization and costs over a 2-year period. The choice of long-acting opioid analgesia does not appear to be a determinant of future medical costs.

Opioids and the gut: pharmacology and current clinical experience

This article reviews the pharmacology and physiology of opiate receptors and the current and potential uses of opioid agonists and antagonists in clinical gastroenterology. Mu-receptors are involved in motor and sensory functions, and their modulation is established for treatment of diarrhea. Mu-antagonists have potential to reverse endogenous (e.g., postoperative ileus) or iatrogenic dysmotility (e.g., opioid bowel dysfunction). Modulation of the function of kappa-receptors may be a novel approach to control visceral pain in functional gut disorders. Results of formal testing of novel opioid modulators are keenly awaited.

Understanding the continuum of palliative care for patients and their caregivers

We describe a process for assisting seriously ill patients and their caregivers in prioritizing their preferences for care during advanced illness. Thirty-two seriously ill patients and their caregivers participated in seven 90-minute focus groups conducted cross-sectionally in Denver, Colorado; San Francisco, California; and Washington State. Fourteen expert-defined end-of-life quality indicators were presented to each group, and quantitative unweighted rankings were obtained through patient and caregiver preferences. Aggregated weightings were used to rank the top five quality measures for exploration of open-ended questions. Pain management was the most important quality indicator among all three groups. Overlap in preferences were found for at least two of the groups for symptom management, monitoring medical issues, advance care preferences and assessment of family and caregiver involvement. Caregivers were more focused on bereavement support. Variation in preferences for end-of-life care by patients and their caregivers reflects the need to understand the individual decision-making regarding end-of-life care. Quality improvement activities are beginning to address these needs.

Caring for children with advanced cancer integrating palliative care

The care of children with advanced cancer is multifaceted. Treatment should focus on continued efforts to control the underlying illness whenever possible. At the same time, children and their families should have access to interdisciplinary care aimed at promoting optimal physical, psychological and spiritual wellbeing. Open and compassionate communication can best facilitate meeting the goals of these children and families. However, there remain significant barriers to achieving optimal care related to lack of formal education, reimbursement issues and the emotional impact of caring for a dying child. Future research efforts should focus on ways to enhance communication, symptom management and quality of life for children with advanced cancer and their families. As efforts to break down barriers and create the evidence base continue, we conclude as follows: this is a most rewarding part of the practice of medicine. A kind word and caring attitude are remembered for decades.

A quantitative and qualitative pilot study of the perceived benefits of autogenic training for a group of people with cancer

This paper describes the application of autogenic training (AT), a technique of deep relaxation and self-hypnosis, in patients diagnosed with cancer,with the aim of increasing their coping ability, and reports the results of a questionnaire survey performed before and after an AT course. A reduction in arousal and anxiety can help individuals to perceive their environment as less hostile and threatening, with implications for improved perceived coping ability. Complementary therapies are considered useful in enhancing symptom relief, overall well-being and self-help when used as adjuvant therapies to allopathic medical interventions. The present study aimed to validate, in an Irish context, the effectiveness of AT as a complementary therapy for patients with cancer. Each participant completed a Hospital Anxiety and Depression Scale and Profile of Mood States questionnaire before and after a 10-week AT course. The results indicated a significant reduction in anxiety and increase in 'fighting spirit' after compared with before training, with an improved sense of coping and improved sleep being apparent benefits of AT practice.

The silent epidemic: tobacco and the evolution of lung cancer and its treatment

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.

Pain in nursing home residents: management strategies

Pain is prevalent and undertreated in nursing home residents, despite the existing wide array of effective pharmacological and nonpharmacological treatment modalities. In order to improve the quality of life of these vulnerable individuals, practitioners require education about the correct approach to assessment and management. Assessment should be comprehensive, taking into account the basic underlying pathology (e.g. osteoarthritis, osteoporosis, peripheral neuropathy, fibromyalgia, cancer) as well as other contributory pathology (e.g. muscle spasm, myofascial pain) and modifying comorbidities (e.g. depression, anxiety, fear, sleep disturbance). Pharmacological management should be guided by a stepped-care approach, modelled after that recommended by the World Health Organization for treatment of cancer pain. Nonopioid and opioid analgesics are the cornerstone of pharmacological pain management. Tricyclic antidepressants and anticonvulsants can be very effective for the treatment of certain types of neuropathic pain. In addition to treating the pain per se, attention should be given to prevention of disease progression and exacerbation, as maintaining function is of prime importance. Nursing home residents with severe dementia challenge the practitioner's pain assessment skills; an empirical approach to treatment may sometimes be warranted. The success of treatment should be measured by improvement in pain intensity as well as physical, psychosocial and cognitive function. Effective pain management may impact any or all of these functional domains and, therefore, substantially improve the nursing home resident's quality of life.