Utilización del citrato de fentanilo oral transmucosa como rescate terapéutico en pacientes con altas dosis de opioides / Use of oral transmucosal fentanyl citrate for therapeutic rescue in patients receiving high doses of opiates

El control del dolor irruptivo (DI) en pacientes oncológicosque tienen controlado su dolor basal con altas dosis deopioides se presenta como complejo. No existen referenciasen la literatura que orienten sobre el fármaco, dosis yvía de administración adecuada para su tratamiento, por loque este se fundamenta en conductas no estandarizadas,basadas en la práctica clínica. Con el presente estudio queremosdar a conocer nuestra experiencia en el tratamientode este tipo de dolor en este tipo de pacientes.Objetivos:Evaluar la efectividad y seguridad de CFOT en el tratamientode las crisis de DI en pacientes oncológicos que tienencontrolado su dolor de base con dosis elevadas, comparándolocon los tratamientos que recibían previamente. Se evaluó, así mismo, el grado de satisfacción del pacienterespecto a la medicación evaluada.Material y métodos:Sobre un total de 280 pacientes oncológicos visitadosen nuestro servicio durante el año 2003, 25 reunían loscriterios requeridos. A todos ellos se les instó a tratar suscrisis de DI con CFOT, con dosis iniciales de 400 mcg, quepodían incrementar, en función de respuesta y efectos adversos.Para ello, se evaluó respuesta clínica según valoraciónEscala Analógica Visual, y se recogieron todos losefectos adversos relacionados con la medicación y reportadospor los pacientes. Por último, se valoró el grado de satisfaccióndel paciente mediante el cuestionario propuestopor Kornick.Resultados:Las dosis media efectiva con la que se controlaba las crisisde DI fue de 600 mcg, la titulación se consiguió en lamayoría de los casos a los 2 días, los efectos adversos fueronlos típicamente observados con el tratamiento opioide.La mayoría de pacientes prefirieron CFOT a sus tratamientosprevios. Los pacientes consideraron las pautas de tratamientocomo sencillas de cumplir.Conclusiones:CFOT puede considerarse como una opción segura yefectiva en el tratamiento de las crisis de DI en pacientesoncológicos que tienen controlado su dolor basal con dosisaltas de opioides. Las dosis de CFOT pueden considerarasecomo bajas en relación a las utilizadas para su dolor basal.Su administración y titulación es sencilla, aunque el pacienterequiere de una educación previa a su uso

The management of breakthrough pain in cancer patientstreated with high doses of opiates raises particularproblems, such as the election of the drug to be used, theappropriate dosage and the route of administration. Noclear guidelines on this issue are found in the medical literature,so each service decides its own particular way of acting.In this paper we review the cases dealt with over aone-year period in terms of the use of high doses of opiatesin cancer patients taken care of in 2003 and treatedwith opiates.Objectives:—To study the group of patients treated with high dosesof opiates.—To use OTFC as rescue drug for breakthrough painevents.—To analyze side and toxic effects.—To determine the preferences of the patients.Material and methods:A population of 280 patients with advanced cancer, 25of which were receiving high doses of opiates. In these patients,breakthrough pain crises were managed with OTFC,starting with 400 micrograms. The satisfaction questionnaireproposed by Kornick was used.Results:—Easy adherence to treatment.—Average effective dose of OTFC: 600 micrograms,median of 627.—Dose titration on the second day.—Seventeen patients preferred OTFC, 6 preferred oralmorphine and 2 were indifferent.Conclusions:Easy use of OTFC for the management of breakthroughpain, requiring low doses compared to the total daily doseof the patient. Patient education is required before its administration

Delayed-type hypersensitivity to subcutaneous enoxaparin.

BACKGROUND: Enoxaparin and other low-molecular-weight heparins are widely used to prevent and treat thromboembolic disorders. Cutaneous reactions secondary to enoxaparin injections include delayed hypersensitivity skin reactions described as erythematous, infiltrated plaques at injection sites. We studied three cases of erythematous infiltrated plaques after enoxaparin injection in order to establish the allergenic importance of this low-molecular-weight heparin. METHODS: Patch tests were performed with sodium heparin, calcium heparin, calcium enoxaparin, and calcium nadroparin. A subcutaneous test with calcium heparin and an intravenous challenge test with sodium heparin were done. A punch biopsy was obtained from an erythematous plaque in one patient. RESULTS: Patch tests were negative to calcium heparin in all patients, positive to enoxaparin and nadroparin in two patients, and positive to sodium heparin in one patient. In two patients, the subcutaneous challenge test was positive, the intravenous challenge test was negative, and the histopathologic appearance of the biopsy resembled a delayed-type hypersensitivity reaction. CONCLUSIONS: These cases provide evidence of type IV hypersensitivity and the possibility of crossed-allergenicity among unfractionated heparin and low-molecular-weight heparins. We show that the subcutaneous challenge test is the most reliable diagnostic measure.

Occupational allergic disease in cereal workers by stored grain pests.

It is well known that workers occupationally exposed to grain dust have a high prevalence of respiratory symptoms, but their pathogenesis remains obscure when sensitization to cereal flour cannot be demonstrated. Storage mites, tenebroids, and cockroaches are stored-grain pests found in grain and cereal products frequently in our area, where the cereal industry is the most important industry. An epidemiological analysis of sensitization of these stored-grain pests was performed on 4379 patients residing in an area of cereal industries. Fifty grain workers were selected for in vivo diagnostic tests with nine genera of mites, Tenebrio molitor and Blatta orientalis. Specific IgE antibodies to the extracts were demonstrated by prick tests and RAST. Association between respiratory symptoms and occupational exposure was confirmed by challenge tests (specific and methacholine). The prevalence of mite sensitization in the total sample studied (4379) was 18.96% (SEM 0.58, 95% CI 16.93-19.19). The prevalence of sensitization to storage mites among mite-sensitive patients was 11.88% (SEM 1.15, 95% CI 9.63-14.3). Among the 50 selected patients the most frequent sensitization was that to Dermatophagoides pteronyssinus (58%), followed by Dermatophagoides frinae (48%), Lepidoglyphus destructor and Tyrophagus putrescentiae (38%), Blomia kulagini (34%), and Acarus siro and Chortoglyphus arcuatus (24%). In addition, 22% of the patients presented negative prick tests and RAST for Dermatophagoides species with positive test to storage mites. Fifty percent of the 50 patients were sensitizated to Tenebrio molitor (SEM 0.7, CI 95% 36-64), and 36% to Blatta orientalis (SEM 0.67, CI 95% 23-49). The identification of mites, tenebroids, and cockroaches in dust samples yields useful data for the diagnosis of our patients.

Occupational allergy to mites in salty ham, chorizo and cheese.

We present three cases of occupational allergy caused by the manipulation of food: cheese, chorizo (typical Spanish salami) and salty ham. A IgE-mediated sensitization is demonstrated by skin tests, RAST and positive challenge tests to Acarus siro and Blomia kulagini of the cheese rind, Euroglyphus maynei of the "chorizo" and Tyrophagus putrescentiae of the salty ham.

[Schizophrenia: subjective theories of illness. An explorative study. Part 2: Relatives]. / Schizophrenie: Subjektive Krankheitstheorien. Eine explorative Studie. Teil 2: Angehörige.

The growing acceptance of Zubin's vulnerability-stressor-modell in research and clinical practice stresses the importance of schizophrenic patients individual coping strategies. Coping strategies are influenced not only by individual cognitions concerning the actual illness but also by opinions of key-persons within the social network of the patient. Research on the acquisition of patients subjective view of the schizophrenic illness has to integrate both the individual psychological resources as well as the social context variables. The present paper reports about in depth open interviews with six patients and their key relatives. The results were derived from a structural analysis of the tape-recorded and transcribed interviews. Patients showed a broad variety of etiological explanations of their illness and expressed a need for more comprehensive information (part 1). Parents stated a more pessimistic prognosis of the course of illness than patients. Both patients and parents complained about the lack of mutual communication about the illness and its symptoms (part 2). Implications of these results concerning psychoeducational programs for patients and families as well are discussed.

[Schizophrenia: subjective illness theories--an explorative study. 1: Patients]. / Schizophrenie: Subjektive Krankheistheorien--Eine explorative Studie. Teil 1: Patienten.

The growing acceptance of Zubin's vulnerability-stressor-model in research and clinical practice stresses the importance of schizophrenic patients individual coping strategies. Coping strategies are influenced not only by individual cognitions concerning the actual illness but also by opinions of key-persons within the social network of the patient. Research on the acquisition of patients subjective view of the schizophrenic illness has to integrate both the individual psychological resources as well as the social context variables. The present paper reports about in depth open interviews with six patients and their key relatives. The results were derived from a structural analysis of the tape-recorded and transcribed interviews. Patients showed a broad variety of etiological explanations of their illness and expressed a need for more comprehensive information (part 1). Parents stated a more pessimistic prognosis of the course of illness than patients. Both patients and parents complained about the lack of mutual communication about the illness and its symptoms (part 2). Implications of these results concerning psychoeducational programs for patients and families as well are discussed.