Venous thromboembolism in patients with advanced cancer under palliative care: additional risk factors, primary/secondary prophylaxis and complications observed under normal clinical practice.

We analyzed the principal risk factors of venous thromboembolism (VTE) (immobilization, recent surgery and previous VTE), prophylaxis with low-molecular weight heparin (LMWH) and complications (i.e. severe bleeding, recurrence and death). Patients with advanced cancer under palliative care (PC) and with VTE, were reviewed during the three years before the study. 71 Patients were diagnosed with VTE. 88.7% were outpatients. The risk factors present were: immobilizations in 28 patients (39.4%), recent surgery in 5 (7%) and previous VTE in 23 (32.5%). Prophylaxis was used in 4 (14.3%) patients with immobilization, no patient with recent surgery, and 10 (43.4%) patients with previous VTE. After diagnosis, all patients received treatment with LMWH in therapeutic dosage. The complications observed were: 6 recurrences (8.5%), 11 VTE-related deaths (15.5%), and bleeding events occured in 8 cases (11.3%), 4 (5.6%) of whom suffered severe bleeding; of these patients, 3 (4.2%) died as a result of the bleeding events. In PC patients with advanced cancer, VTE is a serious complication that conditions control of symptoms. The presence of other risk factors, immobilization and previous VTE, is common and LMWH prophylaxis is limited in clinical practice. The risks vs benefits of anticoagulation need to be counterbalanced.

Rotación opioide a oxicodona: éxito en un caso de dolor neuropático / No disponible

El dolor es un síntoma común en pacientes con cáncer y el dolor neuropático está entre los tipos más difíciles de tratar. Los opioides han tenido un papel limitado en el tratamiento del dolor neuropático. Asociados aantidepresivos tricíclicos o a anticonvulsivantes han logrado un mayor alivio de este tipo de dolor pero su uso está a menudo limitado por sus efectos secundarios indeseables. Presentamos un caso de tumor de pulmón con dolor neuropático producido por compresión medular que fue tratado con éxito con oxicodona (AU)

Pain is a common symptom in patients with cancer and neuropathic pain is among the most difficult to treat type. Opioid treatment has played a limited role in the management of neuropathic pain. Opioids associated to tryciclic antidepressants or anticonvulsants have demonstrated a better relief of this type of pain but their use is limited by unwanted side effects. We report a case of a lung tumour with related neuropathic pain from spinal cord compression which was treated successfully with oxycodone (AU)

Ingresos hospitalarios entre los pacientes atendidos por una Unidad de Cuidados Paliativos domiciliarios / No disponible

Introducción: los pacientes atendidos por Unidades Domiciliarias de Cuidados Paliativos (UCPD) con frecuencia precisan ingreso hospitalario. Objetivos: estudio de las causas que motivan el ingreso de pacientes incluidos en un programa de atención domiciliaria de Cuidados Paliativos en una Unidad Hospitalaria de Cuidados Paliativos (UHCP). Método: estudio retrospectivo de las historias clínicas de pacientes atendidos por la UCPD de Cádiz que ingresaron en la UHCP del Hospital Universitario Puerta del Mar de Cádiz. Resultados: durante el periodo de estudio (dos años) se produjeron 140 ingresos correspondientes a 105 pacientes de los 237 incluidos en el programa (44,30%). Los tumores que precisaron ingreso con más frecuencia fueron los de pulmón (33,33%), mama (12,38%) y colon (9,52%). La disnea fue la principal causa de ingreso (32,38%), seguido por la claudicación familiar (18,10%) y la realización de pruebas diagnóstico-terapéuticas (17,14%). Durante el ingreso fallecieron 85 pacientes (60,71% del total de ingresos). Sólo 32 ingresos fueron indicados por la UCPD. Más de la mitad de los ingresos se produjeron en fin de semana. Conclusiones: a pesar de nuestros esfuerzos un alto porcentaje de pacientes atendidos por una UCPD precisan ingreso hospitalario (AU)

Introduction: patients followed by a Palliative Home Care Team (PHCT) often need a hospital admission. Objectives: to study why patients included in a palliative home care program need hospitalization. Method: a retrospective study. The medical records of patients followed by a PHCT in Cádiz who were hospitalized in the Palliative Care Unit, Hospital Universitario Puerta del Mar were reviewed. Results: for two years we enrolled 237 patients. One hundred and five patients (44.30%) were derived to hospital (total: 140 admissions). Tumors most often found were: lung (33.33%), breast (12.38%), and colon (9.52%) tumors. Dyspnea was the main cause of hospitalization (32.38%), followed by giving up (18.10%) and diagnostic or therapeutic procedures (17.14%). During their stay in hospital 85 patients died (60.71% of total hospital admissions). Only 32 admissions were recommended by the PHCT. More than half of hospitalizations occurred in weekends. Conclusions: despite efforts, a high percentage of patients followed b ya PHCT need a hospital admission

Relación entre factores precipitantes y mortalidad en el delirio agitado en Cuidados Paliativos / Relation of precipitating factors and mortality in agitate delirum of Palliative Care patients

Objetivo: el delirio agitado aparece con frecuencia en los pacientes con enfermedad oncológica avanzada. El objetivo de este estudio es analizarla etiología del delirio agitado y su relación con la mortalidad observada. Método: estudio retrospectivo de 631 pacientes de Cuidados Paliativos. Los factores etiológicos se clasificaron en: opioides, infección, iones metabólico, insuficiencia respiratoria, lesión del sistema nervioso central, o desconocido. Analizamos su relación con la mortalidad y el momento de aparición del delirio. Se aplicó el test de Chi cuadrado para variables cualitativas y t de Student para variables cuantitativas. Resultados: el delirio agitado se diagnosticó en 53 pacientes (8,4%). Edad media 67 años (DE 12,9). La neoplasia primaria se localizaba en pulmón (39,6%), aparato genitourinario (24,5%), aparato digestivo (17,0%), mama (9,4%) y otros (9,4%). Los precipitantes fueron: opioides (26,4%), infección (26,4%), iones-metabólico (17,0%), insuficiencia respiratoria(15,1%), lesión en el sistema nervioso central (7,5%) y desconocido (7,5%). La presencia de estos factores fue distinta dependiendo de que el delirio fuese el motivo de ingreso (opioides 32,4%, infección 29,4%) o apareciese durante la hospitalización (insuficiencia respiratoria 36,8%, infección 21,1%); p = 0,019. Se observó mayor mortalidad durante la hospitalización en los pacientes que presentaron delirio respecto a los que no (67,9vs. 41,2%, OR 3,03, IC 95%: 1,7-5,7). No encontramos diferencia en el número acumulado de factores etiológicos en los pacientes con delirio que fallecieron y en los que no (2,56 vs. 2,59). La mortalidad fue inferior, casi significativo, cuando la infección fue el factor precipitante (50,0 vs. 75,0-78,6%); p = 0,23. Conclusión: la infección y el inicio o aumento de dosis de opioides, factores tratables, fueron los precipitantes más frecuentes de delirio. Ninguno de los factores estudiados, ni el número acumulado de los mismos, se relacionó de una manera significativa a menor mortalidad (AU)

Objective: agitated delirium is frequently detected in patients suffering from advanced cancer. The objective of this study was to analyze the etiology of agitated delirium and the relation to mortality. Method: retrospective study of 631 terminally ill cancer patients. Putative etiologic factors were: opioid therapy, infection, metabolic disorders, respiratory insufficiency, central nervous system lesion or unknown. We tried to find their relation to mortality and onset of delirium. It was used the Chi square test for qualitative variables and t Student for quantitative variables. Results: agitated delirium was diagnosed in 53 patients (8.4%). Mean age was 67 years (SD 12.9); male: female 2: 1. Primary neoplasms were located at lung (39.6%), genitourinary system (24.5%), digestive system (17.0%), breast (9.4%) and others (9.4%). Inducing factors were: opioid therapy (26.4%), infection (26.4%), metabolic disorders (17.0%), respiratory insufficiency (15.1%), central nervous system lesion (7.5%) and unknown (7.5%). Frequency of precipitating factors was different whether the delirium was the cause of admission (opioid therapy 32.4%, infection 29.4%) or was developed during hospitalization (respiratory insufficiency 36.8%, infection 21.1%); p = 0.019. Higher mortality during hospitalization was observed in patients with delirium contrasting with those without it (67.9 vs. 41.2%, OR 3.03, 95% CI: 1.7-5.7). There was no difference in the accumulated number of etiologic factors inpatients with delirium who died and those who did not: 2.56 vs. 2.59. Mortality was lower, near significantly, when infection was the precipitating factor (50.0 vs. 75.0-78.6%); p = 0.23. Conclusion: infection and onset or an increase in the doses of opioids, two treatable causes, were the most recurrent precipitating factors of delirium. None of studied factors neither the accumulated number of them was related to mortality with statistical difference (AU)

[Serial assessment of the nutritional status of patients infected by the human immunodeficiency virus. Role of tumor necrosis factor/its receptors]. / Valoración seriada del estado nutricional de enfermos infectados por el virus de la inmunodeficiencia humana. Papel del sistema factor de necrosis tumoral/receptores del mismo.

In order to analyze the nutritional status of HIV infected patients and the involvement of the tumour necrosis factor-alpha (TNF-alpha) and its soluble receptors (sTNFRI and sTNFRII) in such an status, forty HIV infected patients, with no associated systemic opportunist infections, were prospectively followed for eight months. From each patient the following were obtained: clinical history, dietetic survey, anthropometric measurements, CD4+ T lymphocyte/mm3 count, HIV load, and serum concentration of TNF and sTNFRI and sTNFRII. Patients showed a nutritional disorder which involved mainly the fat compartment (mean tricipital skin fold 9.8 +/- 4.2 mm, that is, 65.7 +/- 27.4% of the ideal fold), associated with a hypocaloric intake (mean daily intake 1,659.5 +/- 543.0 kcal), with normal proportions of the different organic principles. Serum concentrations of TNF (87.9 +/- 79.2 vs 8.7 +/- 6.1 pg/ml, p = 0.048) and its receptors, sTNFRI (6.1 +/- 2.6 vs 1.0 +/- 0.8 pg/ml, p < 0.001) and sTNFRII (41.9 +/- 18.6 vs 6.3 +/- 3.6 pg/ml, p < 0.001) were significantly higher than those detected in a sample of ten healthy controls. No correlation was found between nutritional alterations and concentrations of TNF or its receptors, viral load, and counts of CD4+ T lymphocytes/mm3. Seventeen patients completed the follow-up period. During this period, no significant modifications in the analyzed parameters were observed: tricipital skin fold, arm circumference, serum concentrations of albumin or transferrin, concentrations of tumoral necrosis factor or its receptor and caloric intake. The conclusion is that, despite the detected nutritional alterations in the nutritional status and those in the TNF/receptor system, our data no support and interrelationship between them.