[Prevalence, indication and compliance with the recommendations of prescription of low molecular weight heparin in oncology]. / Prévalence, indication et conformité aux recommandations de prescription d'héparine de bas poids moléculaire en oncologie.

INTRODUCTION: Venous thromboembolism is a common complication in cancer and is the second cause of death below infection. Low molecular weight heparin is the gold standard in venous thromboembolism during cancer. This work aimed to evaluate the prevalence of prescription of low molecular weight heparin used at curative dose and the compliance of our practices with the recommendations. METHODS: A retrospective study was led over a 3-month period, on adult patients suffering from venous thromboembolism who had received low molecular weight heparin at curative dose. RESULTS: A 4% prevalence of prescription of low molecular weight heparin at curative doses has been reported. The results showed an incidental discovery of venous thromboembolism on routine restaging scans in 64% cases. The most found indication was the treatment of deep vein thrombosis (51% cases). According to the dosage, overall compliance of prescription is estimated at 55%. DISCUSSION: The incidental discovery rate (64%) is consistent with the literature that confirms the high incidence of asymptomatic thrombosis. The rate of non-compliant prescriptions could result from a lack of re-evaluation and adjustment of dosages. These results confirm the need to educate practitioners in diagnosing and managing venous thromboembolism.

General anaesthetic agents do not influence persistent pain after breast cancer surgery: A prospective nationwide cohort study.

BACKGROUND: It has recently been suggested that propofol exerts a protective effect on the occurrence of persistent pain after breast cancer surgery. We analysed data from a subcohort taken from a multicentre study to validate this information. OBJECTIVE: The objective of this article is to study the role of the agent used for maintenance of general anaesthesia on the occurrence of persistent pain, with adjustment for multiple pre and peri-operative variables using the generalised linear model. DESIGN: A prospective cohort study. SETTING: Four French university hospitals. PATIENTS: Three hundred and twenty-eight and 362 patients with full dataset, depending on the studied outcome. INTERVENTION: Questionnaires sent at the third and the sixth month after surgery. MAIN OUTCOME MEASURES: The risk of persistent postsurgical neuropathic pain (defined by the DN4 questionnaire) within 6 months after surgery, and the intensity of persistent pain at the sixth month. RESULTS: Axillary lymph node harvesting and previous history of peripheral neuropathy were independent risk factors of persistent postsurgical neuropathic pain, although older age was protective. The same independent risk factors, but not age, explained the intensity of persistent postsurgical pain at the sixth month after surgery. We did not find any effect of the general anaesthetic, whether halogenated agent or propofol, using either unadjusted or adjusted analyses based on covariates or propensity score. CONCLUSION: There does not appear to be a role for the anaesthetic protocol in the occurrence of persistent postsurgical pain. Other already well established hypotheses were confirmed. TRIAL REGISTRATION: ClinicalTrials.gov (ref. NCT00812734).

Pain burden in desmoid tumor patients: a survey of the French Advocacy Group SOS Desmoid.

INTRODUCTION: The French Patient Advocacy Group SOS Desmoid conducted a survey to measure the pain burden of desmoid tumor patients. MATERIAL AND METHODS: We used a structured questionnaire to measure the occurrence and consequences of pain. RESULTS: The pain occurrence was approximately 63%. In one-third of the cases, the pain was permanent. This pain led to severe social and economic consequences. DISCUSSION: The occurrence of pain and its consequences are underestimated among these patients. Pain needs to be closely and precisely measured and monitored in future clinical trials to assess the efficacy of proposed treatments better.

Benefit of robot-assisted laparoscopy in nerve-sparing radical hysterectomy: urinary morbidity in early cervical cancer.

OBJECTIVE: To evaluate the feasibility of nerve-sparing radical hysterectomy in early cervical cancer by robot-assisted laparoscopy and atonic bladder rate. METHODS: This was a retrospective study with consecutive patients in three gynecological oncology departments. Patients with <2 cm cervical cancer had nerve-sparing radical hysterectomy by robot-assisted laparoscopy and pelvic lymphadenectomy. Two days after surgery, we systematically removed the Foley bladder catheter. RESULTS: The median (range) age and body mass index of the 30 patients were 44 (33-68) years and 23.9 (17.7-39.4) kg/m(2), respectively. The median (range) tumor diameter at the time of surgery was 13 (4-38) mm. The median (range) operative time, blood loss, and number of pelvic lymph nodes (any common iliac lymph nodes) were 305 (180-405) min, 100 (30-1,500) ml, and 18 (7-28). The overall complication rate was 52.3 %, of which 6.7 % atonic bladder. Twenty-eight patients (93.3 %) were discharged 2 days after surgery with spontaneous voiding and no residual urine >100 ml. CONCLUSIONS: Nerve-sparing radical hysterectomy by robot-assisted laparoscopy is feasible in early cervical cancer (<2 cm). A total of 93.3 % of the patients were discharged 2 days after surgery with spontaneous voiding. The next step would be a prospective study with objective urodynamic investigations.

Ziconotide adverse events in patients with cancer pain: a multicenter observational study of a slow titration, multidrug protocol.

BACKGROUND: Ziconotide is a new analgesic agent administered intrathecally. It is challenging to use and can induce several and sometimes serious adverse events. A low initial dosage followed by slow titration may reduce serious adverse events. OBJECTIVE: To determine whether a low starting dosage of ziconotide, followed by slow titration, decreases the incidence of major adverse events associated with ziconotide when used for intractable cancer pain. STUDY DESIGN: Observational cohort study. SETTING: Three French cancer centers. METHODS: Patients with incurable cancer causing chronic pain rated above 6/10 on a numerical scale while receiving high-dose opioid therapy (more than 200 mg/d of oral morphine equivalent) and/or exhibiting severe opioid-related adverse events received intrathecal infusions of ziconotide combined with morphine, ropivacaine, and clonidine. RESULTS: Seventy-seven patients were included. Adverse events were recorded in 57% of them; moderate adverse events occurred in 51%. Adverse events required treatment discontinuation in 7 (9%) including 5 (6%) for whom a causal role for ziconotide was highly likely; among them 4 (5%) were serious. All patients experienced a significant and lasting decrease in pain intensity (by 48%) in response to intrathecal analgesic therapy that included ziconotide. LIMITATIONS: Limitations include the nonrandomized, observational nature of the study. Determining the relative contributions of each drug to adverse events was difficult, and some of the adverse events manifested as clinical symptoms of a subjective nature. CONCLUSIONS: The rates of minor and moderate adverse events were consistent with previous reports. However, the rate of serious adverse events was substantially lower. Our study confirms the efficacy of intrathecal analgesia with ziconotide for relieving refractory cancer pain. These results indicate that multimodal intrathecal analgesia in patients with cancer pain should include ziconotide from the outset in order to provide time for subsequent slow titration.

Pharmacokinetics of intranasal fentanyl spray in patients with cancer and breakthrough pain.

OBJECTIVE: This study reports the pharmacokinetics, tolerability, and safety of an intranasalfentanyl spray (INFS) in patients with cancer and breakthrough pain (BTP). DESIGN: A randomized, open-label, two-period, crossover trial. PATIENTS: Nineteen adult patients (mean 57.8 years) with BTP, receiving opioid treatment for chronic background pain, from clinical departments in Austria, France, and Norway entered and completed the study. INTERVENTION: Patients were randomly assigned to receive one of six INFS dose sequences: 50/100, 100/50, 50/200, 200/50, 100/200, and 200/100 microg. INFS was administered as a single dose in one nostril. Each dose was separated by a minimum of 48 hours. MAIN OUTCOME MEASURE: Plasma fentanyl concentrations were measured by high-performance liquid chromatography and tandem mass spectrometry from blood samples obtained at 0 (predose) and frequently up to 300 minutes after INFS administration. Blood pressure, peripheral oxygen saturation, and respiratory rate were assessed eight times during each of the two treatment periods. RESULTS: Mean fentanyl plasma concentrations increased in a dose-dependent manner, peaking for all fentanyl doses 9-15 minutes after INFS administration. Median T(max) values were 15, 12, and 15 minutes for the 50, 100, and 200 microg doses of INFS, respectively. Mean (SD) values for C(max) were 351 (+/- 226), 595 (+/- 400), and 1195 (+/- 700) pg/mL, respectively, indicating dose-proportionality. Six patients (31.6 percent) experienced adverse events during the treatment period, the majority being mild in severity. CONCLUSION: INFS at doses of 50, 100, and 200 microg showed a short T(max) and was well tolerated in patients with cancer. These results support INFS use in patients with cancer suffering from BTP.