Polypharmacy and Reversible Drug Induced QT Prolongation in a Patient with Advanced Cancer: Case Report.

QT prolongation is related to the development of ventricular arrhythmias such as Torsade de Pointes (TdP) that can lead to sudden cardiac death. Several drugs used in the treatment of patients with advanced cancer may induce QT prolongation due to their interference with cardiac ion channels. Some patients may be at higher risk if predisposing factors are present. Herein we present the case of a patient with advanced cancer under anti-tumor treatment with radical intention that developed a reversible drug-induced QT prolongation when simultaneously treated with methadone, haloperidol and fluoxetine that presented with chest pain and bradycardia. An approach to cancer patients at risk for drug-induced QT prolongation is discussed highlighting the need of a thorough medication review with a special focus in the patient with polypharmacy.

An eHealth ecosystem for stepped and early psychosocial care in advanced lung cancer: Rationale and protocol for a randomized control trial.

Background: Receiving a diagnosis of lung cancer is an emotional event, not least because it is usually diagnosed at advanced stages with limited life expectancy. Although evidence-based educational, emotional, and social interventions exist, they reach few patients and usually when it is too late. Objective: This project will be carried out in a comprehensive center for cancer care and health research, aiming to study the efficacy, costs, and utility of an eHealth ecosystem to meet the psychosocial needs of patients with advanced lung cancer. Method: We will enroll 76 patients with advanced lung cancer into an eHealth ecosystem of stepped and personalized psychosocial care for 9 months. These patients will be compared with another 76 receiving usual care in a non-inferiority randomized controlled trial. The following main outcomes will be measured every 3 months: emotional distress, spirituality, demoralization, quality of life, and medication adherence. Secondary outcomes will include symptomatology, health education, cost-utility analyses, usability and satisfaction with the platform, and time to detect emotional needs and provide care. Baseline differences between groups will be measured with the Student t-test or chi-square test, as appropriate. We will then compare the main outcomes between groups over time using multilevel linear models, report effect sizes (Hedges' g), and assess non-inferiority. The cost-utility of both interventions will be considered in terms of quality adjusted life years and quality of life given the costs of providing each treatment. Discussion: This randomized controlled trial should provide new evidence on the efficacy and cost-utility of an eHealth ecosystem to deliver personalized and timely psychosocial care to patients with advanced lung cancer. Trial registration: ClinicalTrials.gov ID "NCT05497973".

Family caregiver emotional distress in advanced cancer: the DME-C scale psychometric properties.

BACKGROUND: Family caregivers of patients with advanced illness at end of life often report high levels of emotional distress. To address this emotional distress is necessary to have adequate and reliable screening tools. AIM: This study analyses the psychometric properties and clinical utility of the Family Caregiver Emotional Detection Scale for caregivers of patients with end-stage cancer (DME-C, Spanish acronym) who are receiving palliative care (PC). DESIGN: Multicentre, cross-sectional study. SETTINGS/PARTICIPANTS: Family caregivers of patients with advanced cancer at end of life receiving palliative treatment were interviewed to explore their emotional distress through the DME-C scale and other instruments measuring anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), distress thermometer (DT) and overload (B), as well as a clinical psychological assessment (CPA). RESULTS: 138 family caregivers, 85 (61.6%) female and 53 (38.4%) male, with an average age of 59.69±13.3 participated in the study. The reliability of the scale, as measured by Cronbach's alpha, was 0.76, and its stability over time was 0.734. Positive, significant correlations were found between the DME-C and the scores for anxiety and depression registered on the HADS scale, as well as with the total result of this latter scale and the results for B, the DT and the CPA. A statistical analysis of the receiver-operating characteristic curves showed that the scale has a sensitivity and specificity of 75%, and that the cut-off point for the detection of emotional distress was a score ≥11. Fifty-four per cent of the caregivers displayed emotional distress according to this scale. CONCLUSIONS: The DME-C displays good psychometric properties. It is simple, short, reliable and easy to administer. We believe that the instrument is useful for the detection of emotional distress in the family caregivers of hospitalised patients suffering from end-stage illnesses and receiving PC.

Antitumoral Agent-Induced Constipation: A Systematic Review.

BACKGROUND: Constipation is a common symptom in patients receiving antitumoral treatment. The mechanisms underlying antitumoral agent-induced constipation (ATAIC) are poorly defined. This systematic review aimed to analyze and synthesize the available information related to the prevalence, etiology, and treatment of ATAIC. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted. The review included human studies written in English, French, or Spanish involving patients with cancer and containing information about the prevalence, etiology, and treatment of ATAIC. RESULTS: A total of 73 articles were included. The reported prevalence ranged from 0.8% to 86.6%. Six studies reported an ATAIC prevalence of over 50%. The prevalence rates of constipation of grades 3 and 4 ranged between 0 and 11%. The importance of enteric neuronal integrity in gastrointestinal function was reported. The articles with the highest levels of evidence in relation to ATAIC treatment obtained in this systematic review studied treatments with acupuncture, sweet potato, osteopath, probiotics, and moxibustion. CONCLUSIONS: The prevalence of constipation in patients undergoing antitumoral treatment is very diverse. Studies specifically designed to report the prevalence of antineoplastic treatment-induced constipation are needed. The importance of enteric neuronal integrity in gastrointestinal function was described. Thus, neuroprotection could be an area of research for the treatment of chemotherapy-induced gastrointestinal disorders.

Prevalence and clinical characteristics of patients with Advanced Chronic Illness and Palliative Care needs, identified with the NECPAL CCOMS-ICO© Tool at a Tertiary Care Hospital.

BACKGROUND: The identification of patients with advanced chronic conditions and palliative care needs is essential since their care represents one of the main challenges for public health systems. The study aimed to determine the prevalence and characteristics of inpatients with palliative care needs in different services of a tertiary care hospital using the NECPAL CCOMS-ICO© tool. METHODS: A descriptive, cross-sectional cohort study was conducted in a tertiary hospital. The NECPAL tool identifies patients who require palliative care. Any patient with the Surprise Question with the answer "NO" and at least another question of the tool with a positive answer is considered a positive identification. Patients were classified as Non-NECPAL, NECPAL I-II, and NECPAL III, depending on the NECPAL tool criteria they met. The presence of physical symptoms, emotional distress, and social risk factors was assessed. RESULTS: Of the 602 inpatients, 236 (39.2%) were enrolled. Of them, 34 (14.4%) non-NECPAL, 202 (85.6%) NECPAL+ [105 (44.5%) NECPAL I-II, and 97 (41.1%) NECPAL III]. Physical symptom burden was high (pain intensity ≥ 1 in 68.3% of patients; tiredness ≥ 1 in 83.5%; somnolence ≥ 1 in 50.6%; dyspnea ≥ 1 in 37.9%; anorexia ≥ 1 in 59.5%). 64.1% had emotional distress, and 83.6% had social risk factors. The NECPAL-III group contained a higher percentage of cancer patients, higher demand for palliative care, and greater need for palliative care (p < 0.001). In 50.8% of cases, no referrals were made to psychology, social work, or hospital palliative and supportive care teams. The three services with the higher number of patients with palliative care needs were: Palliative Care Unit (100%), Oncology (54.54%), and Emergency Short-stay Unit (54.16%). CONCLUSION: A high percentage of patients admitted to tertiary care hospitals presented palliative care needs, with multiple unmet physical, emotional, and social needs. Less than 50% are referred to specialized care teams, such as hospital palliative and supportive care teams.

Venting percutaneous radiologic gastrostomy in malignant bowel obstruction: safety and effectiveness in a comprehensive cancer centre.

OBJECTIVE: Approximately 20% of established malignant bowel obstruction (MBO) patients do not respond to pharmacological treatment. In these cases, venting percutaneous radiologic gastrostomy (VPRG) may be useful. Existing evidence is based on retrospective studies with methodological limitations. The purpose of this study is to describe safety and effectiveness for symptom control after VPRG placement in a prospective cohort of MBO patients. METHODS: Complications of VPRG placement, symptom control, destination on discharge and survival were analysed. RESULTS: Twenty-one patients were included, 13 (61.9%) of whom were women. Mean age was 62.7 years (36-85). Local pain (n=8, 38.1%) and peristomal leakage (n=4, 19%) were the most frequent minor complications. No major complications occurred. Nausea and vomiting were relieved in most patients (n=20, 95.2%) after VPRG, and small quantities of liquid diet were introduced to these patients. Median time to death after VPRG was 13 days (IQR 8.6-17.4). Thirteen patients (61.9%) were discharged, with seven of them (33.3%) returning home. CONCLUSIONS: When pharmacological treatment fails, the use of VPRG in MBO patients may be feasible, safe and effective.

Prevalence, Clinical Characteristics, and Management of Episodic Dyspnea in Advanced Lung Cancer Outpatients: A Multicenter Nationwide Study-The INSPIRA-DOS Study.

Background: Episodic dyspnea (ED) is a common problem in patients with advanced lung cancer (LC). However, the prevalence of ED and other related aspects in this patient population is not known. Objectives: To assess and describe the prevalence, clinical features, treatment, and risk factors for ED in outpatients with advanced LC. Design: Multicenter cross-sectional study. Subjects: Consecutive sample of adult outpatients with advanced LC. Measurements: We assessed background dyspnea (BD), the characteristics, triggers, and management of ED. Potential ED risk factors were assessed through multivariate logistic regression. Results: A total of 366 patients were surveyed. Overall, the prevalence of ED was 31.9% (90% in patients reporting BD). Patients reported a median of one episode per day (interquartile range [IQR]: 1-2), with a median intensity of 7/10 (IQR: 5-8.25). ED triggers were identified in 89.9% of patients. ED was significantly associated with chronic obstructive pulmonary disease (p = 0.011), pulmonary vascular disease (p = 0.003), cachexia (p = 0.002), and palliative care (p < 0.001). Continuous oxygen use was associated with higher risk of ED (odds ratio: 9.89; p < 0.001). Opioids were used by 44% patients with ED. Conclusions: ED is highly prevalent and severe in outpatients with advanced LC experiencing BD. The association between intrathoracic comorbidities and oxygen therapy points to alveolar oxygen exchange failure having a potential etiopathogenic role in ED in this population. Further studies are needed to better characterize ED in LC to better inform treatments and trial protocols.

Caregiver emotional distress: external open-behaviour signs.

OBJECTIVES: To determine whether specific external signs of emotional distress (ESED) can be an indirect measure of emotional distress in caregivers. METHODS: A cross-sectional multicentre design was used. 148 primary caregivers of advanced cancer patients attended in four Spanish palliative care units participated in this study. The emotional distress of caregivers was measured using both the Emotional Distress of Caregivers Scale and a psychological interview. Health professionals collected data using a standard clinical interview process after a brief training period. RESULTS: More than half the caregivers (60%) presented with emotional distress. A positive correlation (r=0.566) was found between the intensity of ESED and emotional distress per se. Caregivers who presented emotional distress showed more ESED than those that did not (p<0.01). The study found significant differences for the categories 'visible signs of sadness, fear, crying, feeling overwhelmed' (p<0.001), 'difficulty in separating from the patient: family refuses to let the patient make decisions and insists on care' (p<0.001) and 'visible signs of anger, irritability or frequent disagreement with therapeutic measures' (p<0.001). No significant differences were found with respect to gender. The set of items to measure these external signs presented an adequate reliability assessed using Cronbach's alpha (α=0.773). CONCLUSIONS: The assessment of ESED in caregivers could serve as a useful method to assess their emotional distress. Incorporating the systematic assessment of these external signs as part of the assessment of the emotional distress of primary caregivers could improve the overall assessment and treatment provided to these caregivers.

Acute opioid withdrawal syndrome from naloxone/naloxegol interaction.

Naloxegol is a new peripherally acting mu-opioid receptor antagonist to treat opioid-induced constipation with supposedly no effect on opioid analgesia. We present a patient with cancer-related pain who developed acute opioid withdrawal symptoms due to an interaction between the opioid antagonist naloxone and naloxegol. He was treated with oxycodone sustained release because of poor pain control. For opioid-related constipation, he had been receiving naloxegol. He complained about worsening pain and constipation and oxycodone was switched to oxycodone/naloxone. Shortly after intake, he experienced acute severe agitation, anxiety, sweating, tachycardia, disorientation and yawning without improvement after intravenous midazolam. Only after intravenous morphine administration, symptoms were controlled. He was switched back to the previous oxycodone dose without naloxone, with naloxegol being maintained. In the light of this case we suggest to avoid the use of naloxone and naloxegol in combination, or at least, to use it with extreme caution and monitorisation of tolerance.

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).

¿Telecuidados paliativos? / Telepalliative care?

No disponible

Development of a tool to identify and assess psychosocial and spiritual needs in end-of-life patients: The ENP-E scale.

OBJECTIVE: The goal of this study is to describe the development of a new tool, the Psychosocial and Spiritual Needs Evaluation scale Instrumento de Evaluación de Necesidades Psicosociales y Espirituales del Enfermo al Final de Vida (ENP-E), designed to assess the psychosocial needs of end-of-life (EOL) patients. And, secondarily, to describe the face validity and psychometric properties of this instrument in the Spanish-speaking context. METHOD: The scale was developed through a seven-stage process: (1) literature review; (2) expert panel establishment; (3) discussion and agreement on the most relevant dimensions of psychosocial care; (4) description of key indicators and consensus-based questions to evaluate such dimensions; (5) assessment of the scale by external palliative care (PC) professionals; (6) evaluation by patients; and (7) analysis of scale's psychometrics properties. To assess content validity, 30 PC professionals and 20 patients evaluated the questionnaire. To determine psychometric properties, 150 participants completed these scales: the ENP-E; the Hospital Anxiety and Depression Scale; item 15 from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative; and the Distress Thermometer. RESULT: All respondents evaluated the tool as "excellent." In terms of construct validity, the internal consistency (Cronbach's alpha = 0.74) and temporal stability (test-retest r = 0.74, p < 0.1) were both adequate. On the factorial analysis, four factors (emotional-wellbeing, social support, spiritual, and information) explained 58.4% of the variance. This scale has a sensitivity of 76.3%, specificity of 78.9%, and the cutoff is 28. SIGNIFICANCE OF RESULTS: To provide quality PC to EOL patients, it is essential to determine the psychosocial factors that influence well-being. This requires the use of reliable and specific instruments. The ENP-E is a novel tool that provides a systematic, holistic assessment of the psychosocial needs of EOL patients. Its routine use would allow clinicians to monitor such needs over time. This would, in turn, permit comprehensive, highly individualized interventions to improve effective PC approach.

Efficacy of Cryoablation to Control Cancer Pain: A Systematic Review.

The use of opioids to control cancer pain could be insufficient. Interventional techniques such as a cryoablation have emerged as alternatives to opioids. OBJECTIVES: To summarize the current scientific evidence on the use of cryoablation to control cancer pain. METHODS: A systematic search of the Scopus, PubMed, and Cochrane databases was performed. All articles published before December 31, 2015, whose title or abstract specified cancer pain control as the endpoint were selected. Articles without abstracts and all nonsystematic reviews were excluded. RESULTS: 22 articles were included: 1 randomized clinical trial (RCT), 2 non-RCTs, 1 ambispective study, 9 retrospective studies, 2 nonspecified cohort studies, 3 case series, and 4 case reports. 496 patients with 580 lesions were treated. Lung cancer was the most common primary tumor. 82.8% of the metastases were bone metastases, with or without soft tissue involvement. Cryoablation decreased mean pain scores by 62.5% at 24 hours post-cryoablation, by 70% at 3 months, and by 80.9% at 6 months. Cryoablation was associated with a 44.2% improvement in quality of life after 4 weeks and a 59.6% improvement at 8 weeks. The need for opioids decreased by 75% at 24 hours and by 61.7% at 3 months. Cryoablation in combination with radiotherapy, vertebroplasty, or bisphosphonates appears to be better than cryoablation alone. Complications were highly variable among the studies, but no fatal complications were reported. CONCLUSIONS: Cryoablation is effective in controlling cancer pain without relevant side effects. However, more studies are needed to confirm these results.

Geriatric assessment may help decision-making in elderly patients with inoperable, locally advanced non-small-cell lung cancer.

BACKGROUND: Although concurrent chemoradiotherapy (cCRT) increases survival in patients with inoperable, locally advanced non-small-cell lung cancer (NSCLC), there is no consensus on the treatment of elderly patients. The aim of this study was to determine the prognostic value of the comprehensive geriatric assessment (CGA) and its ability to predict toxicity in this setting. METHODS: We enrolled 85 consecutive elderly (⩾75 years) participants, who underwent CGA and the Vulnerable Elders Survey (VES-13). Those classified as fit and medium-fit by CGA were deemed candidates for cCRT (platinum-based chemotherapy concurrent with thoracic radiation therapy), while unfit patients received best supportive care. RESULTS: Fit (37%) and medium-fit (48%) patients had significantly longer median overall survival (mOS) (23.9 and 16.9 months, respectively) than unfit patients (15%) (9.3 months, log-rank P=0.01). In multivariate analysis, CGA groups and VES-13 were independent prognostic factors. Fit and medium-fit patients receiving cCRT (n=54) had mOS of 21.1 months (95% confidence interval: 16.2, 26.0). In those patients, higher VES-13 (⩾3) was associated with shorter mOS (16.33 vs 24.3 months, P=0.027) and higher risk of G3-4 toxicity (65 vs 32%, P=0.028). CONCLUSIONS: Comprehensive geriatric assessment and VES-13 showed independent prognostic value. Comprehensive geriatric assessment may help to identify elderly patients fit enough to be treated with cCRT.

Tratamiento paliativo de las metástasis óseas dolorosas mediante ultrasonidos focalizados guiados por resonancia magnética. Revisión sistemática / Palliative treatment of painful bone metastases by magnetic resonance guided focused ultrasound. Systematic review

OBJETIVO: Evaluar la eficacia de los ultrasonidos focalizados guiados por resonancia magnética en el tratamiento del dolor producido por metástasis óseas. MATERIAL Y MÉTODOS: Se realizó una revisión sistemática de la literatura en las bases de datos MEDLINE, SCOPUS, EBSCO y Cochrane Database utilizando los siguientes términos de búsqueda y sus asociaciones: «Focused ultrasound surgery», «High intensity focused ultrasound», «Magnetic resonance imaging», «Neoplasms», «Metastases» y «Pain», en el período desde 1960 hasta octubre de 2014. Se incluyeron aquellos trabajos publicados en cuyo abstract se indicara como objetivo la evaluación del control del dolor por metástasis óseas con ultrasonidos focalizados guiados por resonancia magnética. Se evaluó el grado de evidencia de los estudios seleccionados siguiendo el sistema GRADE. RESULTADOS: Se obtuvieron 6 artículos, de los cuales 5 publicaciones correspondieron a estudios prospectivos de cohortes y un estudio fue aleatorizado, simple ciego, controlado contra placebo, multicéntrico. En todos los trabajos se obtuvo una reducción del dolor (entre 64,2-100%) acompañada de una disminución del tratamiento analgésico. Método dispar en la evaluación analgésica. Efectos secundarios (dolor y quemaduras cutáneas, entre otros) bien tolerados y transitorios. CONCLUSIONES: La mayoría de los estudios analizados muestran un nivel de evidencia bajo para poder concluir el grado de eficacia de los ultrasonidos focalizados guiados por resonancia magnética como tratamiento analgésico del dolor secundario a metástasis óseas. Se necesitan más estudios que respalden su uso rutinario

OBJECTIVE: The aim of the study is to evaluate the effectiveness of magnetic resonance-guided high-intensity focused ultrasound in the treatment of pain produced by bone metastases. MATERIAL AND METHODS: A systematic literature review was performed in the MEDLINE, SCOPUS, EBSCO and Cochrane databases, using the following research terms and their associations: 'Focused ultrasound surgery', 'High intensity focused ultrasound', 'Magnetic resonance imaging', 'Neoplasms', 'Metastases' and 'Pain', for the period between 1960 and October 2014. Those published works were included in which it indicated the evaluation of the control of pain due to bone metastasis with magnetic resonance-guided high-intensity focused ultrasound in the objective of its abstract. The level of evidence of the studies selected was evaluated following the GRADE system. RESULTS: Six articles were obtained, of which 5 were prospective cohort studies and one was a randomised, single-blinded, placebo-controlled, multicentre study. A reduction in pain (between 64.2 and 100%) accompanied by a decrease in the use of analgesic treatment was obtained in all the studies. Methods differed in the analgesic evaluation. Side effects (including pain, skin burns, etc. ) were well tolerated and transient. CONCLUSIONS: The majority of studies analysed show a low level of evidence to be able to conclude the level of efficiency of magnetic resonance-guided high-intensity focused ultrasound as an analgesic treatment of pain due to bone metastases. More studies are needed that support its routine use

Uso prolongado de catéter epidural para el manejo paliativo de un paciente con dolor oncológico refractario / Long term epidural catheter for the palliative management of a patient with refractory cancer pain

Presentamos el caso clínico de un paciente con cáncer renal irresecable, que presentaba dolor intenso de características mixtas (nociceptivo y neuropático), con limitación para actividades habituales y afectación en su calidad de vida. Este caso fue tratado mediante la colocación de catéter epidural lumbar para infusión continua de anestésico local más opioide, con adecuada respuesta a largo plazo y sin complicaciones

A clinical case is presented of a patient with unresectable renal cancer, who had mixed intense pain (neuropathic pain and nociceptive pain), with limitations on ordinary activities and impact on quality of life. This case was treated by lumbar epidural catheter placement for continuous infusion of local anesthetic and opioid, with adequate long-term and uncomplicated response

Desarrollo de la escala DME-C: una escala para la detección del malestar emocional de los cuidadores principales de personas con enfermedad avanzada o al final de la vida / Development of the DME-C: A scale for detecting emotional distress in primary caregivers of patients living with advanced illness or approaching end of their lives

Se presenta el desarrollo de la Escala de Detección de Malestar Emocional de los Cuidadores principales de pacientes con enfermedad avanzada o terminal que reciben cuidados paliativos (DME-C). Se describe el proceso de elaboración de la escala. Para ello, se ha revisado la bibliografía existente sobre el tema, se ha establecido un marco teórico de referencia y los criterios que debía cumplir el instrumento de cribado que se iba a elaborar. La escala DME-C consta de 2 partes: 1) 3 preguntas dirigidas a los cuidadores, y 2) la observación realizada por el personal sanitario de la presencia de signos externos de malestar emocional del cuidador. La escala final fue revisada tanto por expertos como por cuidadores. La escala DME-C es una herramienta apropiada para la identificación del malestar emocional de los cuidadores. Proponemos el uso sistemático de la DME-C para una detección precoz e intervención específica del sufrimiento emocional

This paper presents the development of the Detection of Emotional Distress Scale in primary Caregivers (DED-C) of patients living with advanced disease or terminal illness who are receiving palliative care. The scale development process is described. For this purpose, literature has been reviewed and a theoretica framework of study as well as the characteristics of the screening tool have been established. The DED-C scale consists of 2 parts: 1) 3 questions addressed to primary caregivers, and 2) the health care professional’s appreciation or observation of any external signs of emotional distress on behalf of the caregivers. The final scale was reviewed by experts and caregivers. The DED-C scale will be an appropriate tool for identifying caregivers’ emotional distress. We propose the systematic use of DED-C for early detection of and specific intervention on emotional distress

Efficacy and Safety of Methadone as a Second-Line Opioid for Cancer Pain in an Outpatient Clinic: A Prospective Open-Label Study.

INTRODUCTION: Most clinical reports on methadone rotation describe outcomes in hospitalized patients. The few studies that have included outpatients are retrospective. The aim of this study was to assess the efficacy and safety of methadone as a second-line opioid in adult patients with advanced cancer after rotation in routine clinical practice at a palliative care outpatient clinic. PATIENTS AND METHODS: This was a prospective, open-label study of 145 patients whose treatment was rotated from other opioids to methadone. Informed consent was obtained in all cases. The main outcome measure was change in the variable "worst pain" at day 28. Pain and pain interference were assessed with the Brief Pain Inventory, with side effects evaluated according to the Common Terminology Criteria for Adverse Events version 3.0. Pain levels were evaluated at study entry and at days 3, 7, 9, 14, 21, and 28. RESULTS: Rotation to methadone was performed for the following reasons: poor pain control (77.9%), opioid side effects (2.1%), or both (20%). The mean daily oral morphine equivalent dose before rotation was 193.7 mg. The median worst and average pain scores decreased significantly (p < .0001) from baseline to day 28: The median worst pain score decreased from 9 (interquartile range [IQR]: 8-10) to 6 (IQR: 3-8), and the median average pain score decreased from 6 (IQR: 5-7) to 4 (IQR: 2-5). The proportions of patients with moderate to severe worst and average pain decreased by 30.3% and 47.5%, respectively, by day 28. No increase in opioid toxicity was observed during the study. CONCLUSION: In outpatients with advanced cancer, rotation to methadone as a second-line opioid was efficacious and safe when using a tiered scheme with close follow-up by experienced health professionals. IMPLICATIONS FOR PRACTICE: The results of this study, conducted prospectively under real clinical conditions, support the efficacy and safety of oral methadone as a second-line opioid in ambulatory patients with cancer. Moreover, these findings corroborate previously reported outcomes in retrospective outpatient studies and prospective studies that evaluated inpatient populations. Although more research into methadone rotation strategies is still needed, this study describes a successful tiered scheme of oral methadone rotation that was proven safe and effective during follow-up.

Effectiveness of opioid rotation in the control of cancer pain: the ROTODOL study.

OBJECTIVE: To assess the effectiveness of opioid rotation (OR) to manage cancer pain. To describe the adverse events (AEs) associated with OR. SETTING: Thirty-nine tertiary hospital services. PATIENTS: Sixty-seven oncological patients with cancer-related pain treated at outpatient clinics. INTERVENTION: Prospective multicenter study. Pain intensity was scored using a Numerical Rating Scale (NRS) of 0-10. Average pain (AP) intensity in the last 24 hours, breakthrough pain (BTP), and the number of episodes of BTP on the days before and 1 week after OR were assessed. The pre-OR and post-OR opioid were recorded. The presence and intensity of any AEs occurring after OR were also recorded. RESULTS: In the 67 patients evaluated, 75 ORs were recorded. In all cases, the main reason for OR was poor pain control. Pain intensity decreased by ≥2 points after OR in 75.4 percent and 57.8 percent of cases for AP and BTP, respectively. If the initial NRS score was ≥4, a decrease below <4 accounted for 50.9 percent and 32.3 percent of cases for AP and BTP, respectively. The number of episodes of BTP also decreased significantly (p<0.001). A total of 107 AEs were reported, most of which were mild in intensity, with gastrointestinal symptoms predominating. CONCLUSIONS: Opioid rotation appears to be both safe and effective in the management of basal and breakthrough cancer pain.