An oral care protocol intervention to prevent chemotherapy-induced oral mucositis in paediatric cancer patients: a pilot study.

The likelihood of paediatric cancer patients experiencing oral mucositis has increased significantly as high-dose and multiple chemotherapy agents are used in the treatment of childhood cancer in recent years. The resulting oral ulcerative lesions can cause significant pain, dysphagia, alteration in nutritional status and increased risk for localized infections that could disseminate systemically. The purpose of this pilot study was to determine the clinical benefits of an oral care protocol intervention on the prevention and reduction of the severity of oral mucositis in paediatric patients receiving chemotherapy. Fourteen children were enrolled in the study; there were seven children in the control and seven in the experimental group. In the experimental group, children received a preventive oral care protocol consisting of tooth brushing, normal saline rinse and 0.2% chlorhexidine mouth rinse. Children in the control group received usual care according to the study's clinical setting. Data were collected at baseline, then twice a week for 3 weeks. The incidence of ulcerative lesions, severity of oral mucositis and the related pain intensity were used as the main outcome variables. The experimental group exhibited fewer and less painful oral mucositis lesions. The results of this study support the preventive use of oral care protocols in paediatric patients undergoing chemotherapy for cancer treatment.     

Oral cryotherapy reduces mucositis and opioid use after myeloablative therapy—a randomized controlled trial

Introduction Mucositis is a major complication in myeloablative therapy, which often necessitates advanced pharmacological pain treatment, including i.v. opioids. Attempts to prevent oral mucositis have included oral cryotherapy, which has been shown to reduce mucositis, but there is a lack of knowledge concerning the effect of oral cryotherapy on opioid use by reducing the mucositis for patients treated with myeloablative therapy before bone marrow transplantation (BMT). Aim The aim of the present study was to evaluate if oral cryotherapy could delay or alleviate the development of mucositis and thereby reduce the number of days with i.v. opioids among patients who receive myeloablative therapy before BMT. Materials and methods Eighty patients 18 years and older, scheduled for BMT, were included consecutively and randomised to oral cryotherapy or standard oral care. A stratified randomisation was used with regard to type of transplantation. Intensity of pain, severity of mucositis and use of opioids were recorded using pain visual analogue scale (VAS) scores, mucositis index scores and medical and nursing charts. Results This study showed that patients receiving oral cryotherapy had less pronounced mucositis and significantly fewer days with i.v. opioids than the control group. In the autologous setting, cryotherapy patients also needed significantly lower total dose of opioids. Conclusion Oral cryotherapy is an effective and well-tolerated therapy to alleviate mucositis and consequently reduce the number of days with i.v. opioids among patients treated with myeloablative therapy before BMT.     

Dialogues on complex analgesic strategies for difficult pain syndromes

Although the use of oral analgesics for the control of cancer pain has been demonstrated to be successful in most patients, some patients will fail to respond to pharmacological therapy or will suffer unacceptable adverse effects. Experience is accumulating that when adverse effects prevail with oral opioid administration, the analgesic response may be improved by changing the drug and/or the route of administration. Switching to an alternative opioid may further improve the balance between analgesia and adverse effects Despite optimal systemic opioid treatment, in some complicated circumstances it is necessary to find different solutions, including the neuraxial administration of multiple drugs with different characteristics, which are difficult to manage. Three case reports illustrate how complex could be the analgesic approach using multiple analgesic regimens and different routes of administration to effectively manage complex pain syndromes commonly defined as unresponsive.     

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients

Purpose

The aim of this project was to develop clinical practice guidelines on the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and management of oral mucositis (OM) in cancer patients.

Methods

A systematic review of the available literature was conducted. The body of evidence for the use of each agent, in each setting, was assigned a level of evidence. Based on the evidence level, one of the following three guideline determinations was possible: recommendation, suggestion, or no guideline possible.

Results

A recommendation was developed in favor of patient-controlled analgesia with morphine in hematopoietic stem cell transplant (HSCT) patients. Suggestions were developed in favor of transdermal fentanyl in standard dose chemotherapy and HSCT patients and morphine mouth rinse and doxepin rinse in head and neck radiation therapy (H&N RT) patients. Recommendations were developed against the use of topical antimicrobial agents for the prevention of mucositis. These included recommendations against the use of iseganan for mucositis prevention in HSCT and H&N RT and against the use of antimicrobial lozenges (polymyxin–tobramycin–amphotericin B lozenges/paste and bacitracin–clotrimazole–gentamicin lozenges) for mucositis prevention in H&N RT. Recommendations were developed against the use of the mucosal coating agent sucralfate for the prevention or treatment of chemotherapy-induced or radiation-induced OM. No guidelines were possible for any other agent due to insufficient and/or conflicting evidence.

Conclusion

Additional well-designed research is needed on prevention and management approaches for OM.     

Assessing and managing chemotherapy-induced mucositis pain

Acute pain is the major clinical problem associated with mucositis. Mucosal tissue injury is a dose-limiting toxicity of many cancer therapies. Because the number of patients treated with combinations of high-dose chemotherapy agents is likely to increase, more patients are at risk for mucositis. Currently, no consensus exists regarding mucositis prevention, assessment, or treatment. Similarly, research is needed in methods to accurately assess and manage pain for mucositis. Multiple interventional approaches are needed to decrease the emotional and physical distress caused by acute oral pain and mucositis. An assessment tool that includes physical, functional, and pain parameters is presented. Although approaches to prevent and treat mucositis are increasing, appropriate assessment and timely directed interventions can minimize patient distress.     

A comparison of oral mucositis in allogeneic hematopoietic stem cell transplantation between conventional and reduced-intensity regimens

Severe oral mucositis developed in allogeneic hematopoietic stem cell transplantation (HSCT) accompanies intolerable pain and risk for systemic bacteremia infection. Conventional stem cell transplantation (CST) and reduced-intensity regimens for allogeneic HSCT (RIST) may differently affect the occurrence and severity of oral mucositis. Here, we comparatively examined oral mucositis in patients undergoing CST and that in RIST patients to search for measures to alleviate oral mucositis. We retrospectively analyzed the data of 130 consecutive patients undergoing HSCT (conventional, 60; RIST, 70). Oral mucositis was evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. We also investigated the risk factors for severe oral mucositis in each regimen. The incidence of oral mucositis was not significantly different between RIST and CST patients. The use of opioid analgesics to control pain due to oral mucositis was significantly less in patients undergoing RIST compared with those receiving CST. The risk factors for severe oral mucositis, determined by univariate and multivariate analyses, were “younger age (<40)” in CST and “longer duration of neutropenia (≥14?days)” in RIST. Although the incidences of oral mucositis were almost the same, the need for opioid analgesics and the risk factors for severe oral mucositis differed between CST and RIST patients.     

Opioidanalgetika bei “nichtmalignen” Schmerzen—Langzeitbehandlungsergebnisse bei Patienten mit rheumatischen Beschwerden

The oral administration of strong opioids like morphine is a very effective treatment in cancer pain. However, these analgesics are rarely prescribed for patients suffering from severe "non-malignant" pain. We examined the effects of oral opioids (morphine sulphate tablets, buprenorphine and levomethadone) given to patients with intractable rheumatic pain, which were refractory to other therapeutic measures. The origin of pain was inflammation or a degenerative lesion of the spine. Within a period of more than 3 years, 12 patients were treated accordingly. In 9 patients we could achieve sufficient pain relief, two of them showing improvement only after having changed the initially prescribed drug. We had to stop opioid medication in two patients because of side-effects and, moreover, in one patient because of failure to produce analgesia. 775 weeks of treatment were documented until December 31th, 1990, with an individual duration ranging from 11 to 145 weeks. It was necessary to increase the dose of morphine in the course of treatment of one patient, who is up to now being treated for more than 77 weeks. In all other patients the doses were either stable or varied. No severe side-effects such as respiratory depression were associated with long-term opioid therapy. Constipation was observed in 4 patients, nausea in two patients and urinary retention in one patient. These side-effects could be well treated by an additional medication. No drug abuse, dependence or tolerance were observed. Strong opioids are not analgesics of first choice in patients with rheumatic disease, but an opioid medication should be considered-as well as in patients with intractable pain caused by another disease-when alternative therapeutic measures have failed. The principles of opioid medication in rheumatic pain are similar to those in patients with cancer pain.     

Current practices for management of oral mucositis in cancer patients

Many anticancer therapies induce oral mucositis, diminishing the patient's quality of life. Especially in neutropenic patients, it can lead to life-threatening systemic infection. Moreover, it can become a limiting factor in intensive treatment schedules. Many interventions are aimed at reducing trauma and the risk of secondary infection. The institution of good oral hygiene seems to play a crucial part and can be achieved manually or by means of antiseptic agents. More specific antimicrobial therapy may be indicated. In addition, local and/or systemic pain control may be required. The administration of hematological growth factors, cryoprotectants and other agents or measures that may be of help in the management of mucositis are discussed. Electronic publication: 14 December 1998     

Mucositis-Related Morbidity and Resource Utilization in Head and Neck Cancer Patients Receiving Radiation Therapy With or Without Chemotherapy

The objective of this study was to estimate health care-resource utilization in head and neck cancer (HNC) patients. This was a prospective, longitudinal, multicenter, noninterventional study of mucositis in patients receiving radiation with or without chemotherapy for HNC. Mouth and throat soreness and functional impairment were measured using the Oral Mucositis Weekly Questionnaire-HNC. Resource utilization data were obtained from patient interviews and recorded from the patient's medical chart. Seventy-five patients were enrolled from six centers. Fifty (67%) patients received concurrent chemoradiation therapy; 34 (45%) received intensity-modulated radiation therapy. Over the course of treatment, 57 (76%) patients reported severe mouth and throat soreness. Pain and functional impairment because of mouth and throat soreness increased during the course of therapy despite the use of opioid analgesics in 64 (85%) of the patients. Complications of radiation therapy resulted in increased patient visits to physicians, nurses, and nutritionists. Thirty-eight (51%) patients had a feeding tube placed. Twenty-eight patients (37%) were hospitalized, five of whom were hospitalized twice; of the 33 admissions, 10 (30%) were designated as secondary to mucositis by their treating physician. Mean length of hospitalization was 4.9 days (range: 1–16). This study demonstrates that mucositis-related pain and functional impairment is associated with increased use of costly health resources. Effective treatments to reduce the pain and functional impairment of oral mucositis are needed in this patient population.     

Pain management in ambulatory surgery.

Successful ambulatory surgery is dependent on analgesia that is effective, has minimal adverse effects, and can be safely managed by the patient at home after discharge. A number of studies have identified that the provision of effective postoperative analgesia is inadequate for a significant proportion of patients. The following discussion details the current available analgesic options for ambulatory surgery patients and the rationale for their use. Preemptive analgesia should be given to all patients unless there are specific contraindications. Consideration should be given to the use of long-acting oral COX-2 selective nonsteroidal anti-inflammatory drugs (NSAIDs) and long-acting oral opioids to treat postoperative pain. A standardized multimodal postdischarge analgesic regimen tailored to the patient's expected postoperative pain levels should be prescribed. Patient follow-up by telephone questionnaire will confirm those surgical procedures that result in mild or moderate-to-severe postoperative pain and the effectiveness of treatment plans.     

Topical diclofenac epolamine patch 1.3% for treatment of acute pain caused by soft tissue injury

Acute pain caused by musculoskeletal disorders is very common and has a significant negative impact on quality‐of‐life and societal costs. Many types of acute pain have been managed with traditional oral non‐steroidal anti‐inflammatory drugs (NSAIDs) and selective cyclooxygenase‐2 inhibitors (coxibs). Data from prospective, randomised controlled clinical trials and postmarketing surveillance indicate that use of oral traditional NSAIDs and coxibs is associated with an elevated risk of developing gastrointestinal, renovascular and/or cardiovascular adverse events (AEs). Increasing awareness of the AEs associated with NSAID therapy, including coxibs, has led many physicians and patients to reconsider use of these drugs and look for alternative treatment options. Treatment with NSAIDs via the topical route of administration has been shown to provide clinically effective analgesia at the site of application while minimising systemic absorption. The anti‐inflammatory and analgesic potency of the traditional oral NSAID diclofenac, along with its physicochemical properties, makes it well suited for topical delivery. Several topical formulations of diclofenac have been developed. A topical patch containing diclofenac epolamine 1.3% (DETP, FLECTOR^® Patch), approved for use in Europe in 1993, has recently been approved for use in the United States and is indicated for the treatment of acute pain caused by minor strains, sprains and contusions. In this article, we review the available clinical trial data for this product in the treatment of pain caused by soft tissue injury.     

Alternative treatments of breakthrough pain in patients receiving spinal analgesics for cancer pain

Patients who experience a poor response to different systemic opioid trials (oral and intravenous) are candidates for spinal treatment. Breakthrough pain occurring in this group of patients is challenging for physicians. This phenomenon has never been described in this context and the treatment is quite difficult, as patients already demonstrated a poor response to systemic opioids. We report a preliminary experience of alternative methods, including the intrathecal injection of local anesthetic boluses as needed, or alternatively, the use of sublingual ketamine. Twelve consecutive patients with advanced cancer and pain were selected for intrathecal treatment after receiving different trials with systemic opioids. During intrathecal therapy, pain flares not responding to high doses of intravenous morphine were treated with intrathecal boluses of local anesthetics titrated to achieve the best balance between analgesia and adverse effects, or with sublingual ketamine (25 mg), according to their preference. Pain and symptoms were recorded for each episode of breakthrough pain during hospital admission. Effective pain control was achieved in all the episodes treated within 10 minutes with either method, without relevant complications. A mean volume of 0.6 mL of levobupivacaine (LB) 0.25% (1.5 mg) was effective within a few minutes and was well tolerated in patients receiving a continuous intrathecal infusion of a combination of morphine and LB in different doses. Similarly, ketamine in doses of 25 mg sublingually was effective and relatively well tolerated. Despite the difficult clinical situation of these patients, these approaches controlled almost all breakthrough pain events previously unresponsive to relatively high doses of intravenous opioids. These intensive treatments should be reserved for a very selected population and initiated in an appropriate setting with frequent monitoring facilities and skilled nursing.     

Neuraxial infusion in patients with chronic intractable cancer and noncancer pain

Ever since the application in 1980 of morphine for spinal analgesia in patients with refractory cancer pain, spinal infusion therapy has become one of the cornerstones for the management of chronic, medically intractable pain. Initially, spinal infusion therapy was indicated only for patients with cancer pain that could not be adequately controlled with systemic narcotics. However, over the past decade, there has been a significant increase in the number of pumps implanted for the treatment of nonmalignant pain. Indeed, "benign" pain syndromes, particularly failed back surgery syndrome, are the most common indication for intrathecal opiates. As we have gained more experience with this therapy, it has become apparent that even intrathecal opiates, when administered in the long term, can be associated with problems such as tolerance, hyperalgesia, and other side effects. Consequently, long-term efficacy has not been as significant as had been hoped. Because of the difficulties associated with long-term intrathecal opiate therapy, much of the research, both basic and clinical, has focused on developing alternative nonopioid agents to be used either alone or in combination with opiates. Clinical trials have been and continue to be conducted to evaluate drugs such as clonidine, SNX-111, local anesthetics, baclofen, and many other less common agents to determine their efficacy and potential toxicity for intrathecal therapy. This article reviews the agents developed as alternatives to intrathecal opiates.     

Oral glutamine for the prevention of oral mucositis associated with high-dose paclitaxel and melphalan for autologous bone marrow transplantation

OBJECTIVE: To determine the effect of glutamine suspension on mucositis associated with the administration of high-dose preparative regimens for bone marrow transplantation. METHODS: We performed a retrospective analysis of 21 consecutive patients receiving high-dose paclitaxel and melphalan as the preparative regimen for autologous peripheral blood stem-cell transplantation for metastatic breast cancer between January 1997 and December 1997. Glutamine suspension was given as swish-and-swallow administration every four hours around the clock starting day-7, for a total dose of 24 g/d. RESULTS: The group given oral glutamine suspension demonstrated significantly fewer days of mucositis and a lower maximum grade of mucositis. The treatment group also had fewer days of parenteral morphine for pain relief. The group that did not receive glutamine required an average of 5.22 days of patient-controlled analgesia (PCA) morphine; the glutamine group did not require PCA morphine. The total days of narcotic pain relief were decreased in the glutamine group; however, this did not reach statistical significance. Qualitatively, the patients in the glutamine group had less oral ulceration and bleeding, and were able to tolerate liquids sooner than those in the nonglutamine group. Patients tolerated the glutamine suspension well. CONCLUSIONS: This study showed that around-the-clock administration of oral glutamine may decrease both the severity and duration of mucositis associated with high-dose bone marrow transplant preparative regimens. The decrease in severity and duration of mucositis translated into reduced parenteral narcotic use. A prospective, randomized, controlled trial is needed to determine future applications of glutamine in the support of patients undergoing high-dose chemotherapy.     

Continuing education. Home care of the epidural analgesia patient: the nurse's role

Spinal analgesia offers a viable alternative for many patients with cancer whose pain cannot be controlled by systemic narcotics. The success of this therapy depends largely on the effectiveness of the home health nurse in instructing patient and caregivers, monitoring catheter care, and assessing the patient's response to treatment.     

Evaluation of nutritional status in head and neck radio-treated patients affected by oral mucositis: efficacy of class IV laser therapy

Purpose

To retrospectively evaluate the role of class IV laser therapy in the amelioration of nutritional status of patients affected by oral mucositis due to radiotherapy of the head and neck region during oncological treatment.

Methods

Sixty-three oncological patients were included in this study. All patients were affected by tumors in the head and neck region and had developed oral mucositis during radiotherapy. Forty-two patients had been treated by high-power laser therapy whereas 21 patients had been managed with traditional medications. Data collection included weight measurement (kilogram) and body mass index (BMI) calculation (mass (kilogram)/(height) (square meter)) on the first and last day of radiotherapy. In addition, gender, age, pathology, and the kind of oncological treatment have been considered.

Results

Laser-treated patients decreased less in BMI during radiotherapy (p?=?0.000). Patients treated by combined oncological treatments (radiotherapy and/or chemotherapy and/or surgery) had a higher weight loss during radiotherapy (p?=?0.015). According to a multivariate regression analysis, the only variable which significantly influenced the reduction of BMI was laser treatment (p?=?0.000).

Conclusions

Laser therapy is actually considered one of the recommended remedies for the healing of oral mucositis due to cancer treatments. Healing of mucositis can deeply influence the feeding capacity of patients, through reduction of pain and improvement of chewing and swallowing capacities. It also allows lowering the costs for hospitalization and supportive care. Laser therapy should become part of nutritional interventions in oncological patients affected by oral mucositis.     

Clinical Uses of Intrathecal Therapy and Its Placement in the Pain Care Algorithm

Intrathecal drug delivery is an effective treatment option for patients with severe chronic pain who have not obtained adequate analgesia from more conservative therapies (eg, physical therapy, systemic opioids, nonsteroidal anti‐inflammatory drugs, antidepressants, and anticonvulsants). This review focuses on, but is not limited to, the 2 agents currently approved by the U.S. Food and Drug Administration for intrathecal analgesia: preservative‐free morphine and ziconotide (a nonopioid, selective N‐type calcium channel blocker). We describe the appropriate use of intrathecal therapy in the management of severe chronic pain, based on current best practices. Topics addressed here include patient selection, trialing, dosing and titration, adverse event profiles, long‐term management, intrathecal therapy for cancer‐related pain, and the placement of intrathecal therapy in the pain care algorithm. In appropriately selected patients with chronic pain, intrathecal therapy can provide substantial pain relief with improved functioning and quality of life. Successful long‐term management requires ongoing patient monitoring for changes in efficacy and the occurrence of adverse events, with subsequent changes in intrathecal dosing and titration, the addition of adjuvant intrathecal agents, and the use of concomitant oral medications to address side effects, as needed. Based on an infrequent but clinically concerning risk of overdose, granuloma, and other opioid‐induced complications, nonopioid therapy with ziconotide may be preferred as a first‐line intrathecal therapy in patients without a history of psychosis or allergy.     

短波紫外线治疗仪治疗急性白血病患者化疗后口腔黏膜炎疗效评价

[目的]探讨短波紫外线治疗仪治疗急性白血病住院患者化疗后口腔黏膜炎(OM)的临床疗效.[方法]按照入院先后顺序不同将接受化疗后出现OM的急性白血病住院患者分为观察组和对照组,对照组采用亚叶酸钙、维生素B12漱口液漱口、表面喷涂金因肽、金喉健等治疗;观察组在对照组的基础上加用ZYY-9增强型短波紫外线治疗仪进行照射治疗.观察两组在治疗14d后OM的治疗效果.[结果]治疗14d后,观察组痊愈率(89.3%)明显高于对照组痊愈率(64.3%);观察组在疼痛感消失时间、溃疡面积缩小50%和溃疡面愈合所需时间上明显短于对照组,差异均有统计学意义(均P<0.05).[结论]短波紫外线治疗仪可提高OM的痊愈率,缩短OM的痊愈时间,使用安全、方便,患者易于接受,值得临床推广应用.     

Oral mucositis in patients receiving reduced-intensity regimens for allogeneic hematopoietic cell transplantation: comparison with conventional regimen

Goals of work  

Severe oral mucositis induced by allogeneic hematopoietic cell transplantation (HCT) is associated with intolerable pain and risk of systemic bacteremia infection. Differences between conventional HCT and reduced-intensity regimens for allogeneic HCT (RIST) may influence the occurrence and severity of oral mucositis. Here, we evaluated oral mucositis in patients undergoing RIST and compared the results with those in conventional allogeneic HCT patients to facilitate predictive measures for mucositis.     

Oral ketamine as an adjuvant to oral morphine for neuropathic pain in cancer patients.

To evaluate the role of oral ketamine as an adjuvant to oral morphine in cancer patients experiencing neuropathic pain, 9 cancer patients (5 men, 4 women) taking maximally tolerated doses of either morphine, amitriptyline, sodium valproate, or a combination of these drugs for intractable neuropathic pain, and reporting a pain score of >6 on a 0-10 scale, were studied prospectively to evaluate analgesia and adverse effects. Ketamine in the dose of 0.5 mg/kg body weight three times daily was added to the existing drug regimen. Patients were taught to maintain a pain diary wherein they daily recorded their pain, sedation, and vomiting scores, and other side effects. A decrease of more than 3 from the baseline in the average pain score, or a score of < or =3 was taken as a successful response. Seven patients exhibited a decrease of more than 3. Four patients experienced nausea, of which one had vomiting. Two developed loss of appetite. Eight patients reported drowsiness during the first two weeks of therapy (P = 0.001), and this gradually improved over the next two weeks in 5 of these 8 patients. Three patients withdrew from the study, two owing to excessive sedation and another due to a "feeling of unreality." None of the patients reported visual or auditory hallucinations. This experience suggests that low dose oral ketamine is beneficial and effective in the management of intractable neuropathic pain in patients with advanced cancer. However, its utility is limited in some patients by the adverse effects that accompany its use.