Switching Ratio from Parenteral to Oral Methadone 1:1.2 Is Safer Compared with Ratio 1:2 in Patients with Controlled Cancer Pain: A Multicenter Randomized-Controlled Trial (RATIOMTD-010810).

Background: The most commonly used switching ratio from parenteral to oral methadone is 1:2. Methadone is highly bioavailable and a lower ratio might result in similar analgesia with less toxicity. Objective: To compare success and side effects with two ratios from parenteral to oral methadone: 1:2 versus 1:1.2 in hospitalized patients with cancer pain. Design: A multicenter double-blind randomized clinical trial. Settings/Particiants: Inpatients with well-controlled cancer pain with parenteral methadone requiring rotation to the oral route. Measurements: Outcomes included pain intensity (Brief Inventory Pain), opioid toxicity (Common Toxicology Criteria for Adverse Events), and methadone dose. Success was defined as no toxicity with good pain control at 72 hours. Results: Thirty-nine of forty-four randomized patients were evaluable: 21 in ratio 1:2 and 18 in ratio 1:1.2. Seventy-one percent male. Median age 65 years. No significant differences in basal clinical characteristics between both groups. Median methadone dose pre/post switching was 24.5 mg ±13.5 and 49 mg ±27.3 for ratio 1:2, versus 23.3 mg ±9.4 (p: not significant) and 28 mg ±11.3 (p < 0.01) for ratio 1:1.2. Pain was well controlled without differences between both ratios. Drowsiness at day +1 (p < 0.017) and myoclonus at day +3 (p < 0.019) were more prevalent in group 1:2. Success was observed in 12 patients in ratio 1:2 versus 18 in ratio 1:1.2 (p < 0.001). Methadone side effects were observed in 12 patients in ratio 1:2 (mainly neurotoxicity symptoms) versus 2 in ratio 1:1.2 (p < 0.005). Conclusion: Ratio 1:1.2 when changing from parenteral to oral methadone resulted in lower toxicity and no difference in analgesia. More conservative dose adjustment during methadone route change should be considered. European Clinical Trials Register (EudraCT No. 2010-024092-39).

Manifestaciones sintomáticas en la infección por COVID-19 / Symptomatic manifestations in COVID-19 infection

La pandemia COVID-19 se ha propagado rápidamente por todo el mundo, produciendo una alta mortalidad. Ha obligado a reorganizar todos los sistemas sanitarios. La Unidad de Cuidados Paliativos del Hospital Universitario La Paz se transformó en una unidad para la atención a pacientes con infección por COVID-19 con el fin de colaborar en la atención a los mismos. Nos enfrentábamos al reto de asegurar un buen control de la sintomatología, que pasaba por una valoración lo más sistemática posible, siendo conscientes de la dificultad en el contexto del aislamiento y situación clínica de los pacientes. Presentamos una revisión narrativa sobre las manifestaciones sintomáticas y nuestra experiencia como Unidad de Cuidados Paliativos integrada en la atención COVID-19 en un hospital de tercer nivel de Madrid. Se priorizó un perfil de pacientes con enfermedad avanzada y comorbilidad alta para el ingreso en esta unidad. Esta integración contribuyó significativamente a tener una mayor influencia en la forma de actuación en la atención al final de la vida en todo el hospital. Los cuidados paliativos deben formar parte de los equipos de atención de cualquier emergencia sanitaria, como una pandemia. Es imprescindible para una adecuada atención de la sintomatología y del final de la vida. Es necesaria la recogida sistemática de los síntomas por la repercusión clínica que tiene sobre el paciente, la necesidad de un tratamiento específico y su implicación pronóstica

The COVID-19 pandemic has spread rapidly around the world, producing high mortality. It has forced the reorganization of all health systems. The Palliative Care Unit of the Hospital Universitario La Paz was transformed into a unit for the care of patients with COVID-19 infection in order to collaborate in the care of these patients. We faced the challenge of ensuring good control of the symptoms, which were assessed as systematically as possible, being aware of the difficulty in the context of the isolation and clinical situation of the patients. We present a narrative review of symptomatic manifestations and our experience as a Palliative Care Unit integrated in COVID-19 care in a third level hospital in Madrid. A profile of patients with advanced disease and high comorbidity was prioritized for admission in this unit. This integration contributed significantly to having a greater influence on the way end-of-life care is provided throughout the hospital. Palliative care should be part of the care teams in any health emergency, such as a pandemic. It is essential for adequate symptomatology and end-of-life care. Systematic collection of symptoms is necessary because of the clinical impact on the patient, the need for specific treatment and its prognostic implications

Manejo y control de síntomas en pacientes hospitalizados con demencia avanzada / Management and control of symptoms in hospitalized patients with advanced dementia

INTRODUCCIÓN: La dificultad que supone concluir que un paciente con demencia avanzada se encuentra al final de su vida conlleva a que no siempre se cumpla con la adecuación del esfuerzo terapéutico, pudiendo ser sometido a técnicas diagnósticas y terapéuticas desproporcionadas. El presente estudio pretende analizar el manejo paliativo y el control de síntomas en estos pacientes. MATERIAL Y MÉTODOS: Estudio observacional, descriptivo y retrospectivo mediante la revisión de historias clínicas. Se incluyeron de forma consecutiva pacientes mayores de 75 años ingresados en las Unidades Geriátricas de Agudos de tres hospitales de Madrid con diagnóstico de demencia avanzada y que fallecieron por cualquier causa, hasta alcanzar un total de 50 individuos por hospital. RESULTADOS: Se obtuvo una muestra de 150 pacientes con una edad media de 89 años. Se registró dolor en el 18 %, disnea en el 55 % y agitación en el 30 %. El 87 % tenía prescritos opioides, el 67 % benzodiacepinas y antitérmicos, el 21 % neurolépticos y el 31 % antibióticos en las últimas 72 horas de vida. La orden médica de no reanimación estaba registrada en el 91 % de las historias clínicas y en el 96 % de los casos se informó a los familiares. En el 70 % se retiró el tratamiento específico en las 72 horas previas al exitus. CONCLUSIONES: A pesar de que un gran porcentaje de pacientes con demencia avanzada en situación de últimos días recibió tratamiento sintomático, identificándose la fase de terminalidad, la adecuación de cuidados al fi nal de la vida continúa siendo un área de mejora

INTRODUCTION: The difficulty of concluding that a patient with advanced dementia is at the end of his or her life means that the adequacy of therapeutic efforts is not always achieved, and patients may be subjected to disproportionate diagnostic and therapeutic techniques. This study aims to analyze palliative management and symptom control in these patients. MATERIAL AND METHODS: This was an observational, descriptive, and retrospective study based on a review of medical records. Patients over 75 years of age, admitted to the acute geriatric units of three hospitals in Madrid with a diagnosis of advanced dementia, and who subsequently died from any cause were included. A total of 50 individuals were enrolled per hospital. RESULTS: A sample of 150 patients with an average age of 89 years was obtained. Pain was reported in 18 %, dyspnea in 55 %, and agitation in 30 %. In all, 87 % had opioids prescribed, 67 % benzodiazepines and antithermals, 21 % neuroleptics, and 31 % antibiotics during the last 72 hours of life. A medical non-resuscitation order was recorded in 91 % of the medical records, and 96 % of cases were reported to family members. In 70 % specific treatments were withdrawn within the final 72 hours of life. CONCLUSIONS: Although a large percentage of patients with advanced dementia in their last days received symptomatic treatment, and their terminal phase identified, the adequacy of end-of-life care remains an area open for improvement