Nurse practitioner led pain management the day after caesarean section: A randomised controlled trial and follow-up study

BackgroundPain on the day after caesarean section is often treated with controlled-release oxycodone to supplement the decline in analgesia from intrathecal opioids. Evidence suggests that caesarean birth is a biopsychosocial experience where a comprehensive approach is needed that promotes control and participation in pain management.ObjectivesThis study compared immediate-release oxycodone integrated with supportive educational strategies to controlled-release oxycodone. A follow-up phase aimed to explore pain over three months.DesignThis study was a two-group parallel randomised controlled trial.SettingA metropolitan hospital in Australia with a birthing suite, operating rooms, and a postnatal unit.ParticipantsEnglish-speaking women scheduled for elective caesarean section were mailed trial information. Exclusion criteria included contraindications to intrathecal analgesia, herpes simplex infection, a history of chronic pain, opioid tolerance, or substance abuse. A total of 131 participants were recruited and randomised out of 298 eligible participants.MethodsGroup allocation was undertaken using sequentially numbered opaque sealed envelopes. The nurse practitioner intervention commenced on the day after surgery with immediate-release oxycodone alongside supportive strategies. The control group received scheduled doses of controlled-release oxycodone. All participants could request additional oxycodone or tramadol. Primary outcomes were pain intensity and secondary outcomes included patient global impression of change, pain interference, opioid consumption, and maternal perception of control. A follow-up phase evaluated pain outcomes over three months.ResultsThe final sample size was 122, with 61 participants in each group. Pain intensity scores were analysed by linear mixed regression models. There were no statistical differences over 24 h between the control and intervention groups at rest (p = 0.40, 95% CI – 4.8 mm, 11.9 mm) or on sitting or moving (p = 0.561, 95% CI –15.2 mm, 8.3 mm). Patient global impression of change was significant over three hours (p = 0.014, OR = 2.5, 95% CI 1.2, 5.3). The intervention group reported less pain interference while consuming less oxycodone (p < 0.05). There was no difference between groups in terms of perceived control over pain management (p = 0.273, 95% CI –16.2 mm, 4.6 mm). The follow-up analysis graded 5.9% of participants as experiencing severe pain interference. Chronic pain following caesarean was associated with postnatal depression (p < 0.001).ConclusionsThe research showed that a nurse practitioner intervention can improve pain management following caesarean section. The results underscore the influence of biological, psychological, and social factors on acute pain. Hence, this study reinforces the need for a biopsychosocial approach to acute pain management following caesarean delivery.     

Efficacy and safety of morphine-6-glucuronide (M6G) for postoperative pain relief: A randomized,double-blind study

AimsThe aim of the study was to assess analgesia and safety effects of a range of intravenous doses of M6G (10, 20 and 30 mg/70 kg), compared to placebo, in postoperative patients.MethodsIn a randomized, multicentre, double-blind study, patients undergoing knee replacement surgery under spinal anaesthesia were administered one of three doses of M6G, or placebo, 150 min after spinal nerve block. Morphine rescue medication was available via a PCA pump. The key index of analgesic activity was determined as the amount of morphine consumed by the patient over 12 and 24 h after M6G administration. Time to first use of rescue medication, VAS and global pain assessment scales were also recorded. Safety was assessed by monitoring supine blood pressure, heart rate, respiratory rate and body temperature and typical opioid side-effects of PONV and sedation.ResultsA total of 170 patients were dosed with study medication. M6G induced a dose-related reduction in morphine use over 24-h that reached statistical significance compared to placebo at M6G 30 mg/70 kg. There was no clear relationship between M6G dose and time to first use of PCA morphine. Pain relief was similar in all groups. M6G showed small, but inconsistent effects on the cardiovascular system and on sedation and no effects were observed on respiration or PONV.ConclusionM6G induced long-lasting dose-related analgesic effects in postoperative patients with limited effects on cardiorespiratory systems or of opioid-like side-effects. M6G is an effective opioid for the treatment of moderate to severe postoperative pain.     

Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS)

PurposePostoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population.DesignOur primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure.MethodsFollowing Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period.FindingsNinety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003).ConclusionsThere was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.     

A Randomized,Double-Blind,Placebo-Controlled Study of Fentanyl Buccal Tablets for Breakthrough Pain: Efficacy and Safety in Japanese Cancer Patients

ContextRapid-onset opioids for treating breakthrough pain (BTP) in patients with cancer are needed in the Japanese care setting.ObjectivesTo examine the efficacy and safety of fentanyl buccal tablets (FBTs) for treating BTP in Japanese cancer patients.MethodsThis was a randomized, double-blinded, placebo-controlled study. In subjects receiving around-the-clock (ATC) opioids at doses of 30 mg or more to less than 60 mg or 60–1000 mg of oral morphine equivalents (low and high ATC groups), dose titration was started from 50 to 100 μg FBT, respectively. Subjects whose effective dose was identified were randomly allocated to a prearranged administration order of nine tablets (six FBTs and three placebos), one tablet each for nine episodes of BTP (double blinded). Efficacy and safety of FBT were assessed for patients overall, and also for the low and high ATC groups.ResultsA significant difference was observed between FBT and placebo for the primary endpoint of pain intensity difference at 30 minutes. The analgesic onset of FBT was observed from 15 minutes in several secondary variables (e.g., pain relief). Adverse events were somnolence and other events associated with opioids were mostly mild or moderate. Of the low and high ATC group subjects, an effective FBT dose was identified in 72.2% and 73.1%, respectively.ConclusionThe safety of FBT and its analgesic effect on BTP were confirmed in Japanese cancer patients receiving opioids. Our findings suggest that analgesic onset may occur from 15 minutes after FBT, and that FBT can be administered to patients with low doses of ATC opioids.     

Management of Moderate-to-Severe Dyspnea in Hospitalized Patients Receiving Palliative Care

ContextBenzodiazepines (BZDs) are commonly prescribed for relief of dyspnea in palliative care, yet few data describe their efficacy.ObjectivesTo describe the management of moderate-to-severe dyspnea in palliative care patients.MethodsChart review of inpatients with moderate or severe dyspnea on initial evaluation by a palliative care service. We recorded dyspnea scores at follow-up (24 hours later) and use of BZDs and opioids.ResultsThe records of 115 patients were reviewed. The mean age of patients was 64 years and primary diagnoses included cancer (64%, n = 73), heart failure (8%, n = 9), and chronic obstructive pulmonary disease (5%, n = 6). At initial assessment, 73% (n = 84) of the patients had moderate and 27% (n = 31) had severe dyspnea. At follow-up, 74% (n = 85) of patients reported an improvement in their dyspnea, of which 42% (n = 36) had received opioids alone, 37% (n = 31) had BZDs concurrent with opioids, 2% (n = 2) had BZDs alone, and 19% (n = 16) had received neither opioids nor BZDs. Logistic regression analysis identified that patients who received BZDs and opioids had increased odds of improved dyspnea (odds ratio 5.5, 95% CI 1.4, 21.3) compared with those receiving no medications.ConclusionMost patients reported improvement in dyspnea at 24 hours after palliative care service consultation. Consistent with existing evidence, most patients with dyspnea received opioids but only the combination of opioids and BZDs was independently associated with improvement in dyspnea. Further research on the role of BZDs alone and in combination with opioids may lead to better treatments for this distressing symptom.     

Lack of Benefit From Paracetamol (Acetaminophen) for Palliative Cancer Patients Requiring High-Dose Strong Opioids: A Randomized,Double-Blind,Placebo-Controlled,Crossover Trial

ContextThe adjunctive use of paracetamol (acetaminophen) with strong opioids has become entrenched practice in palliative care pain management, despite little evidence to support its use.ObjectiveThe study aim was to investigate potential analgesic benefits of 4 g of paracetamol daily for palliative cancer patients requiring high-dose opioids.MethodsThirty-one patients, using at least 200 mg of oral morphine equivalent daily, were recruited to a prospective, double-blinded, randomized, crossover trial. Patients received usual medications plus 4 g of paracetamol or placebo for five days each in random order. Primary outcome, effect on pain, was assessed using daily diaries, including a numerical rating scale (NRS) from zero (no pain) to 10 (unbearable) and recording numbers of breakthrough analgesics. Secondary outcomes—nausea, vomiting, cognitive impairment, constipation, and overall well-being—were assessed using the NRS. Data from the last four days of each treatment were analyzed. Patients also indicated in which part of the study their pain was better controlled.ResultsTwenty-two patients, requiring a median dose of 255 mg of oral morphine equivalent daily, completed the trial. There were no significant order or treatment-by-order interaction effects for any variable; paired t-tests were conducted to investigate change in mean levels on outcome variables with placebo vs. paracetamol. For none of the variables was there a statistically significant difference when assessed with placebo compared with paracetamol. No change approached clinically significant levels, with a mean difference in rated pain of 0.16, and mean difference of 0.42 for a number of breakthrough medications. Fifteen patients were undecided whether paracetamol improved pain.ConclusionsThese data do not support the common practice of adding regular paracetamol daily as an adjunct to high-dose opioids for pain control in cancer patients receiving palliative care.     

Frequency,Indications, Outcomes,and Predictive Factors of Opioid Switching in an Acute Palliative Care Unit

The aim of this study was to prospectively evaluate the frequency, indications, outcomes, and predictive factors associated with opioid switching, using a protocol that had been clinically applied and viewed as effective for many years. A prospective study was carried out on a cohort of consecutive cancer patients who were receiving opioids but had an unacceptable balance between analgesia and adverse effects, despite symptomatic treatment of side effects. The initial conversion ratio between opioids and routes was as follows (mg/day): oral morphine 100 = intravenous morphine 33 = transdermal fentanyl 1 = intravenous fentanyl 1 = oral methadone 20 = intravenous methadone 16 = oral oxycodone 70 = transdermal buprenorphine 1.3. The switch was assisted by opioids used as needed, and doses were changed after the initial conversion according to clinical response in an acute care setting. Intensity of pain and symptoms associated with opioid therapy were recorded. A distress score (DS) was calculated as a sum of symptom intensity. A switch was considered successful when the intensity of pain and/or DS, or the principal symptom necessitating the switch, decreased to at least 33% of the value recorded before switching. One hundred eighteen patients underwent opioid substitutions. The indications for opioid switching were uncontrolled pain and adverse effects (50.8%), adverse effects (28.8%), uncontrolled pain (15.2%), and convenience (4.2%). Overall, 103 substitutions were successful. Ninety-six substitutions were successful after the first switching, and a further substitution was successful in seven patients who did not respond to the first switch. The mean time to achieve dose stabilization after switching was 3.2 days. The presence of both poor pain control and adverse effects was related to unsuccessful switching (P < 0.004). No relationship was identified between unsuccessful switching and the opioid dose, opioid sequence, pain mechanism, or use of adjuvant medications. Opioid switching was an effective method to improve the balance between analgesia and adverse effects in more than 80% of cancer patients with a poor response to an opioid. The presence of both poor pain relief and adverse effects is a negative factor for switching prognosis, whereas renal failure is not.     

Effectiveness and Tolerability of Amidotrizoate for the Treatment of Constipation Resistant to Laxatives in Advanced Cancer Patients

ContextConstipation is a common problem for advanced cancer patients, and is generally inadequately treated.ObjectivesThe aim of this study was to prospectively evaluate the effectiveness and tolerability of amidotrizoate (AM) in patients unresponsive to current laxatives.MethodsA consecutive sample of advanced cancer patients was surveyed. Inclusion criteria were no bowel movements for three days despite receiving regular doses of senna or lactulose. AM 50 mL was administered orally; the dose could be repeated the day after, based on clinical judgment and/or patients’ preference. Age, sex, primary tumor, previous abdominal surgery, chemotherapy and radiotherapy performed in the previous month, and the use of opioids were recorded. Nausea, the presence of early satiety, and fluid and food intake also were measured. Time to first bowel movement was recorded, and adverse effects attributable to AM.ResultsNinety-nine patients were surveyed (36 women/63 men). The mean age was 65.7 years (SD ± 12.2) and the mean Karnofsky score was 46.8 (SD ± 9.4). Patients had no bowel movement for a mean of four days (SD ± 1.8, range 3–15 days). A total of 80.8% of patients were receiving opioids in doses of mean daily oral morphine equivalents of 164 mg (SD ± 235). After AM administration (mean 9.9 ± 6.5 hours), 44.4% of patients had a bowel movement within 24 hours. This effect was associated with significant improvement of other symptoms and was independent of age (P = 0.513), gender (P = 0.090), Karnofsky status (P = 0.979), days of constipation (P = 0.198), concomitant chemotherapy (P = 0.098) or radiotherapy (P = 0.414), the use of opioids (P = 0.361), opioid doses (P = 0.420), and primary tumor (P = 0.231). The treatment was more effective in patients who had previous abdominal surgery (HR = 3.33).ConclusionAM was found to be an easy and inexpensive breakthrough medication to induce a bowel movement in about 45% of advanced cancer patients not responsive to common laxatives, with limited and acceptable adverse effects.     

Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy

ObjectiveTo determine whether buprenorphine maintenance alters intrapartum or postpartum pain or medication requirements.MethodsSixty three patients treated with buprenorphine for opioid dependence during pregnancy (vaginal n = 44; cesarean n = 19) were matched retrospectively to control women. Analgesic medication and pain scores (0–10) were extracted from the medical record. Primary endpoint: opioid utilization postpartum (oxycodone equivalents). Secondary endpoints: pain scores and intrapartum analgesia.ResultsThere were no differences in intrapartum pain or analgesia. Following vaginal birth, buprenorphine maintained women had increased pain (buprenorphine 2.7 (1.7, 4.0); control 2.1 (1.2, 3.0), p = 0.006) but no increase in opioid utilization (buprenorphine: 11.8 ± 24.8; control 5.4 ± 10.4 mg/24 h, p = 0.10); following cesarean delivery both pain (buprenorphine: 5.1 (4.1, 6.1); control: 3.3 (2.5, 4.1), p = 0.009) and opioid utilization (buprenorphine: 89.3 ± 38.0, control: 60.9 ± 13.1 mg/24 h, p = 0.004) were increased.ConclusionBuprenorphine maintained women have similar intrapartum pain and analgesic needs during labor, but experience more postpartum pain and require 47% more opioid analgesic following cesarean delivery.     

The Role of a Low-Dose Ketamine-Midazolam Regimen in the Management of Severe Painful Crisis in Patients With Sickle Cell Disease

ContextAcute pain is one of the main causes of hospital admission in sickle cell disease, with variable intensity and unpredictable onset and duration.ObjectivesWe studied the role of a low-dose intravenous (IV) ketamine-midazolam combination in the management of severe painful sickle cell crisis.MethodsA retrospective analysis was performed with data from nine adult patients who were admitted to the intensive care unit with severe painful sickle cell crises not responding to high doses of IV morphine and other adjuvant analgesics. A ketamine-midazolam regimen was added to the ongoing opioids as an initial bolus of ketamine 0.25 mg/kg, followed by infusion of 0.2–0.25 mg/kg/h. A midazolam bolus of 1 mg followed by infusion of 0.5–1 mg/h was added to reduce ketamine emergence reactions. Reduction in morphine daily requirements and improvement in pain scores were the determinants of ketamine-midazolam effect. The t-tests were used for statistical analysis.ResultsNine patients were assessed, with mean age of 27 ± 11 years. Morphine requirement was significantly lower after adding the IV ketamine-midazolam regimen. The mean ± SD IV morphine requirement (milligram/day) in the pre-ketamine day (D0) was 145.6 ± 16.5, and it was 112 ± 12.2 on Day 1 (D1) of ketamine treatment (P = 0.007). The Numeric Rating Scale scores on D0 ranged from eight to ten (mean 9.1), but improved to range from five to seven (mean 5.7) on D1. There was a significant improvement in pain scores after adding ketamine-midazolam regimen (P = 0.01).ConclusionLow-dose ketamine-midazolam IV infusion might be effective in reducing pain and opioid requirements in patients with sickle cell disease with severe painful crisis. Further controlled studies are required to prove this effect.     

The clinical use of spinal opioids,part 1

Spinal opioids are effective analgesics for surgical and non-surgical pain. Central and systemic side effects are less frequent than with epidural local anaesthetics or parenteral opioids. This review focuses on the analgesic efficacy of spinal opioids and their combination with local anaesthetics for postoperative analgesia, including patient-controlled epidural analgesia. Intrathecal administration of opioids has some advantages over their administration by the epidural route. Several factors may influence selection of the opioid; however, in most situations morphine is the drug of choice. Thoracic epidural administration of opioids seems to have no clinically important advantages over the lumbar route in terms of quality of analgesia, adverse effects, doses required or pulmonary function. However, evidence suggesting that effective postoperative analgesia can significantly improve postoperative morbidity in patients at risk is accumulating. In such patients, combined use of epidural local anaesthetics and opioids may become the technique of choice for postoperative analgesia. However, there is no evidence that this would have any clinically relevant benefit in low-risk patients.     

Evaluating a medical directive for nurse-initiated analgesia in the Emergency Department

ObjectivesAlthough acute pain is a common presentation in the Emergency Department (ED), analgesics are often delayed until the patient is seen by a physician. We assessed the effect of a medical directive for nurse-initiated analgesia on time to first dose of analgesics, proportion of patients receiving analgesics in less than 30 min, and total length of stay in the ED.MethodsA medical directive for nurse-initiated analgesia was introduced in our ED in October 2011. This before-after health record review included all patients presenting to the ED with musculoskeletal back pain in 4 month periods before and after implementation of the medical directive.ResultsA total of 524 cases were reviewed, of which 401 were included – 201 and 200 in the before and after implementation groups respectively. After implementation there was a shorter time to first dose of analgesic (mean of 118 vs 160 min, p < 0.001), and a higher proportion of patients receiving analgesics in the first 30 min (20% vs 4%, p < 0.001). However there was no difference in total proportion of patients receiving analgesics (71% vs 67%, p = 0.46) or total length of stay in the ED (337 vs 323 min, p = 0.51).ConclusionsA medical directive for nurse-initiated analgesia in the ED was associated with significantly reduced time to the first dose of analgesic, and increased the proportion of patients receiving analgesics within 30 min. We can conclude that medical directives for nurse-initiated analgesia effectively improve the timeliness and quality of care for patients with acute pain.     

Racial discrimination predicts greater systemic inflammation in pregnant African American women

PurposeChronic exposure to racial discrimination by pregnant African American women may lead to allostatic overload; thereby, predisposing women to systemic inflammation. Thus, the goal of this study was to examine if experiences of racial discrimination are related to systemic inflammation in pregnant African Americans.MethodsA sample of 96 African American women from Chicago completed questionnaires and had blood drawn during the second trimester of pregnancy (19.7 ± 2.5 weeks).ResultsExperiences of racial discrimination were associated with higher cytokine levels of interleukin (IL)-4 (B = 2.161, 95% CI = 1.02–3.30, p < .001) and IL-6 (B = 1.859, 95% CI = .61–3.11, p = .004) when controlling for covariates.ConclusionThese findings suggest that experiences of racial discrimination may cause physiological wear and tear on the body leading to alteration of immune functions. Nurses should inquire about women's experiences of racial discrimination and make referrals for community or church support groups for women who report racial discrimination.     

Antecedents and consequences of emotional work in midwifery: A prospective field study

BackgroundGiven the effort made in today's birthing rooms to increase women's childbirth satisfaction, special attention is directed to midwives’ expressions of authenticity (namely to display emotions that he/she actually experience) in birth encounters.ObjectivesTo explore antecedents and consequences of emotional work strategies expressed in a specific birth encounter, to (1) understand the specific factors in a midwife–birthing woman encounter, namely parity (whether or not it is a first birth), use of epidural analgesia, induction of labor, and instrumental birth that stimulate the use of deep or surface acting; (2) test the link between emotional work strategies and birthing experience, and (3) assess whether associations between the midwife's choice of strategy (deep acting or surface acting), and the woman's childbirth experience is moderated by the birthing woman's perception of the midwife's emotional work strategies.DesignA prospective-correlational field study.Participants104 births, selected by a convenience sampling method—including 24 midwives and 104 birthing women, in one birthing room in Israel.MethodsData were collected by validated questionnaires at two time points: immediately after labor and 48 h after labor.ResultsLinear mixed model analyses revealed that of the antecedents to emotional work strategies, epidural analgesia was negatively associated with surface acting (β = −.301, p < .05); primigravida was significantly associated with deep acting (β = 611, p < .01) and negatively associated with surface acting (β = −.433, p < .01); induction of birth was not associated with deep or surface acting (p > .05), and instrumental birth was significantly associated with deep acting (β = −.590, p < .05) and positively associated with surface acting (β = .444, p < .05). Regarding consequences of emotional work strategies, the midwife's engagement with surface acting was negatively related to the woman's birthing experience (β = −.155, p < .05), whereas the relationship between midwife's engagement in deep acting and the woman's satisfaction also depended on the latter's perception that the midwife had engaged in deep acting (β = −.096, p < .05).ConclusionsThe midwife–birthing woman encounter is becoming globally significant for improving childbirth outcomes. Therefore, these findings offer empirical support for the importance of the midwife's expression of authenticity toward the birthing woman in improving her childbirth experience, especially when the woman perceives the midwife's emotional work strategy accurately. Also noteworthy are the aforementioned conditions that shape the midwife's engagement in deep acting or surface acting, with important recommendations to improve women's childbirth experiences.     

Nasal Tramadol delivery system: A new approach for improved pain therapy

The present work investigates Tramadol nasal delivery for effective analgesia with a rapid onset of action.The pharmacokinetic and pharmacodynamic behavior of Tramadol, a non-opiate analgesic drug, following its administration to rodents from a nasal delivery system was compared to oral aqueous solution.Following Tramadol nasal administration in animals at a dose of 10 mg/kg, a C_max value of 2421 ± 651 ng/ml was obtained as compared to a four time lower value after oral delivery (644 ± 349 ng/ml). The high plasma concentration was achieved at 10 min (t_max), indicating a rapid systemic absorption of the drug.Tramadol nasal delivery system treatment in animal Writhing model at a relative low dose of only 5 mg/kg significantly increased the analgesic effect, as compared to the oral administration, both 30 min before and immediately with pain induction.The local safety of Tramadol nasal system was good with no histological or nasal cavity changes.The outcomes of this work are that nasal administration of Tramadol could improve pain therapy and shorten its onset of action.The treatment by the nasal pathway could overcome the side effects associated with parenteral and oral delivery. Furthermore, due to the rapid and efficient delivery of the drug to the blood, nasal administration of Tramadol could be considered for the treatment of breakthrough pain.     

Appetite and adverse effects associated with radiation therapy in patients with head and neck cancer

PurposeThe relationship between radiation treatment and adverse effects resulting in changes in appetite was studied in patients with head and neck (H&N) cancer.Methods and samplePath analysis was used to evaluate the following factors in 117 patients receiving radiation therapy for H&N cancer: daily fluctuations in saliva production, analgesic use, frequency of oral care, subject characteristics, and appetite.ResultsAt 20 Gy of radiation, appetite was affected by Brinkman index value, age, and sensitivity to taste (R² = 0.48, p < 0.001); at 30 Gy of radiation, appetite was affected by frequency of oral care, xerostomia symptoms, age, sensitivity to taste, and oral mucositis (R² = 0.52, p < 0.001); and at 50 Gy of radiation, appetite was affected by low saliva production in the morning, frequency of oral care, xerostomia symptoms, sensitivity to taste, analgesic use, and oral mucositis (R² = 0.62, p < 0.001).ConclusionsThe results of this study suggest that care taken to avoid a decrease in appetite due to adverse effects of radiation therapy should differ according to the dosage and schedule of radiation therapy. These findings represent important data for health care professionals to understand and support appropriate dietary intake and improved quality of life for H&N cancer patients receiving radiation therapy.     

Proprioceptive neuromuscular facilitation training improves pain-related and balance outcomes in working-age patients with chronic low back pain: a randomized controlled trial

BackgroundProprioceptive neuromuscular facilitation training and general trunk exercises have been applied to treat chronic low back pain patients. However, there is currently little study to support the use of one treated intervention over the other to improve clinical outcomes and balance ability.ObjectiveTo examine the effects of proprioceptive neuromuscular facilitation training on pain intensity, disability and static balance ability in working-age patients with chronic low back pain.MethodsForty-four chronic low back pain participants aged 18–50 years were randomized either to a three-week proprioceptive neuromuscular facilitation training or to a control group receiving general trunk exercises. Pain intensity, disability and static balance ability were measured before and after the three-week intervention.ResultsThe proprioceptive neuromuscular facilitation training intervention showed a statistically significantly greater reduction in pain intensity and improved functional disability than the controls at three weeks (between-group difference: pain intensity 1.22 score, 95% CI: 0.58 to 1.88, p < 0.001; disability 2.23 score, 95% CI: 1.22 to 3.24, p < 0.001. The proprioceptive neuromuscular facilitation training intervention also had statistically better parameters of static balance ability than the control group (between-group difference: ellipse sway area during eye opened and closed conditions 129.09 mm², 95% CI: 64.93 to 175.25, p < 0.01 and 336.27 mm², 95% CI: 109.67 to 562.87, p < 0.05, respectively; the centre of pressure velocity during eye opened and eye closed conditions 6.68 mm/s, 95% CI: 4.41 to 8.95, p < 0.01 and 6.77 mm/s, 95% CI: 4.01 to 9.54, p < 0.01, respectively).ConclusionThe three-week proprioceptive neuromuscular facilitation training provides better pain intensity, disability and static balance ability than general trunk exercises for working-age individuals with chronic low back pain but the effects do not reach the clinical meaningful level. The therapists should consider carefully when making recommendations regarding these interventions, taking into account effectiveness and costs.     

Opioid Switching in Patients With Advanced Cancer Followed at Home. A Retrospective Analysis

ContextOpioid switching has been found to improve opioid responsiveness in different conditions. However, data on opioid switching performed at home are almost nonexistent, despite the fact that most patients are followed at home.ObjectivesThe aim of this retrospective survey was to determine frequency, indications, usefulness, and safety of opioid switching when treating advanced cancer-related pain in patients followed at home.MethodsA retrospective review of data from patients with advanced cancer followed at home by three home care teams for a period of two years was performed. Patients who had their opioids switched were selected. Reasons for switching opioid doses and routes of administration and outcomes were collected.ResultsTwo hundred one (17%) of 1141 patients receiving “strong” opioids were switched. The mean Karnofsky Performance Status score was 35.6, and the median survival was 30 days. The most frequent reason to switch was for convenience, and the most frequent switch was to parenteral morphine. In most patients, a better analgesic response was observed. Patients who were switched to parenteral morphine had a shorter survival in comparison with other opioid sequences (P < 0.0005). After switching, opioid doses were increased by 23% and 41%, after a week and at time of death, respectively.ConclusionOpioid switching was useful for most patients in the home environment, at least in less complex circumstances, when done by experienced home care teams. Prospective studies are needed to provide information about the decision to admit to hospital for this purpose and the predictive factors that may relatively contraindicate transportation to a facility in severely ill patients.