Should we treat pain in the elderly palliative care cancer patients differently?

Opioids are considered the cornerstone of pain management in palliative care. Available data suggest that older patients use different analgesics and lower opioid doses compared to younger patients. However, it has not been elucidated yet whether such dosing is associated with worse pain levels or shorter survival in the palliative care setting. We evaluated the relationship among pain scores, quality of life, opioid dose, and survival in palliative care cancer patients in a hospice setting. A total of 137 palliative care cancer patients were analyzed prospectively. We divided patients into two groups using the age of 65 as a cut-off value. Younger patients exhibited significantly higher pain ratings (5.14 vs. 3.59, p=0.01), although older patients used almost 20 mg less oral morphine equivalent (OME) on arrival (p=0.36) and 55 mg OME/day less during the last week (p=0.03). There were no differences in survival between the two groups (17.36 vs. 17.58 days). The elderly patients also used nonsteroidal analgesics less often and paracetamol more often. Hence, using lower opioid doses in older palliative care cancer patients does not result in worse pain rating, and could be a plausible approach for pain management in this patient group.

Endoscopic retrograde cholangiopancreatography-induced and non-endoscopic retrograde cholangiopancreatography-induced acute pancreatitis: Two distinct clinical and immunological entities?

Acute pancreatitis (AP) is common gastrointestinal disease of varied aetiology. The most common cause of AP is gallstones, followed by alcohol abuse as an independent risk factor. With the increased need for invasive techniques to treat pancreatic and bile duct pathologies such as endoscopic retrograde cholangiopancreatography (ERCP), AP has emerged as the most frequent complication. While severe AP following ERCP is rare (0.5%), if it does develop it has a greater severity index compared to non-ERCP AP. Development of a mild form of AP after ERCP is not considered a clinically relevant condition. Differences in the clinical presentation and prognosis of the mild and severe forms have been found between non-ERCP AP and post-endoscopic pancreatitis (PEP). It has been proposed that AP and PEP may also have different immunological responses to the initial injury. In this review, we summarise the literature on clinical and inflammatory processes in PEP vs non-ERCP AP.

ERCP induced and non-ERCP-induced acute pancreatitis: Two distinct clinical entities?

Acute pancreatitis (AP) is a common gastrointestinal disease of varied etiology; however, the most common causes of AP are gallstones and alcohol abuse. AP has emerged as the most frequent complication after endoscopic retrograde cholangiopancreatography (ERCP). Post-ERCP pancreatitis is generally a clinically irrelevant condition; however, it can be severe or even fatal in up to 0.8% of cases. Different clinical courses and outcomes have been observed between mild and severe AP of different etiologies (i.e., non-ERCP AP and post-ERCP AP), which opens the discussion as to whether they are the same or distinct clinical entities.

Diagnosis of Irritable Bowel Syndrome: Role of Potential Biomarkers.

Irritable bowel syndrome is a disorder diagnosed on symptom-based criteria without inclusion of any objective parameter measurable by known diagnostic methods. Heterogeneity of the disorder and overlapping with more serious organic diseases increase uncertainty for the physician's work and increase the cost of confirming the diagnosis. This paper is an attempt to summarize the efforts to find adequate biomarkers for irritable bowel syndrome, which should shorten the time to diagnosis and reduce the cost. Most of the reviewed papers were observational studies from secondary care institutions. Since publication of the Rome III criteria in 2006, most recent studies use these for the recruitment of IBS patients. This is a positive step forward as future studies should use the same criteria, facilitating comparison of their results. Among the studied biomarkers, most evidence is provided for fecal calprotectin. Cutoff values for fecal calprotectin have still to be investigated prior to inclusion in the irritable bowel syndrome diagnostic algorithm.

Fecal Calprotectin and serum chromogranin A as potential biomarkers of irritable bowel syndrome symptom severity.

Irritable bowel syndrome (IBS) is a disorder of the lower gastrointestinal (GI) tract, which manifests as abdominal pain and/or discomfort accompanied by altered bowel function, in the absence of structural pathology. The onset and precipitation of IBS is the result of an interaction among several factors, including psychological distress, altered GI sensation and processing of sensory information as well as GI inflammation. These factors have varying contributions to disorder etiology in different patients, and in line with that, there is now emerging evidence about a low-grade inflammation in a subgroup of IBS patients. Because IBS diagnosis is based on the ROME III criteria, with the exclusion of structural pathology, patients are often exposed to numerous invasive and unpleasant tests. In order to decrease the cost of repeated testing, while simultaneously alleviating patients' anxiety, research should be aimed at detecting cost-effective biomarkers. We hypothesize chromogranin A (CgA) and fecal Calprotectin (FC) could be used to eliminate possible organic causes of IBS symptoms. Also, we hypothesize FC could be helpful in detecting IBS patients with low-grade inflammation. Forty-eight outpatients with IBS (76% females) completed a set of psychosocial measures (HRQoL, STAI, BDI, VSI, SF-36), and their FC and CgA levels were obtained. We found elevated CgA levels in 4 patients, but CgA levels were not related to any of the psychological measures used. Elevated FC levels were found in 12 patients. FC levels significantly correlated with the physical component of health related quality of life (HRQoL) (r48=-.42, p<.01). In addition, one-way ANOVA's were performed to test possible differences in psychosocial measures depending on the patient's FC status. The analysis showed only one significant difference. Patients with the highest levels of FC had significantly lower physical component of HRQoL compared to the other two groups of patients.

Crohn's disease in women.

This article provides an overview of the obstetric and gynecological manifestations of Crohn's disease (CD). High incidence of the new onset of the disease in young women in their reproductive years demands special concern from physicians involved in their treatment. Pregnant women with CD are considered high-risk patients, regardless of disease activity index, due to associated complications. Predominately described complications are premature birth, low birth weight, and congenital anomalies. To minimize the risk for adverse pregnancy/birth outcomes, it is recommended that remission be achieved before conception. Treatment of CD in pregnant women is similar to that among the nonpregnant population, and there is no valid reason to terminate it, since most of the drugs are proven to be safe. Women with CD who wish to conceive or are already pregnant need to be properly advised according to the newest guidelines on the subject, given by the European Crohn's and Colitis Organization. Gynecological manifestations are another special feature of CD. They are important in that they may facilitate early recognition of the underlying disease, which usually stays unrecognized for years before intestinal manifestation; in this way, the underlying manifestations are often mistreated.