Combined Effect of Opioids and Corticosteroids for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review

Dyspnea is a prognostic factor that affects the quality of life of terminal cancer patients, and many reports have described opioid treatment for dyspnea alleviation. Here, we retrospectively evaluated differences in the effects of various opioids administered concomitantly with corticosteroids on dyspnea in 20 terminal-stage cancer patients (13 men, 7 women; mean age [range]: 71 [49–94] years) who received opioids concomitantly with corticosteroids. Effectiveness was assessed throughout administration using the Support Team Assessment Schedule, Japanese version (STAS-J), particularly the subscale indicating how strongly a patient is affected by symptoms. The effectiveness of combined opioid and corticosteroid therapy against dyspnea and the opioid dose comprised the primary and secondary foci, respectively. Among concomitantly treated patients, STAS-J scores at initiation (mean ± SD: 3.1 ± 0.24) and lowest recorded STAS-J scores (1.4 ± 0.22) differed significantly (P = .0034) among those receiving morphine, but not among those receiving oxycodone (P = .068) or fentanyl (P = .18). Concomitant opioid and corticosteroid treatment was associated with a ≥2-point STAS-J score improvement in 14/20 patients (effectiveness: 70%). The opioid dose did not significantly affect dyspnea alleviation. We conclude that concomitant opioid and corticosteroid treatment can effectively alleviate dyspnea in terminal cancer patients.     

Range of Effective Corticosteroid Doses for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review

This study aimed to determine the range of mean cumulative corticosteroid doses that could effectively palliate dyspnea in opioid-treated patients with terminal cancer and to investigate the demographic or biochemical factors predictive of corticosteroid responsiveness. To this end, responders and nonresponders were compared with regard to corticosteroid dose and whether they had initiated opioid use before or concomitantly with corticosteroid use. A logistic regression analysis was conducted to assess the impacts of demographic and biochemical factors on corticosteroid effectiveness. The final sample comprised 20 patients who satisfied the selection criteria. The responders accounted for 70% of the total sample (n = 14) and experienced the strongest effect with regard to dyspnea palliation at a mean cumulative dose equivalent to 64.4 mg prednisolone. However, no factors predictive of response were identified. In summary, this retrospective study identified effective corticosteroid doses for dyspnea alleviation in terminal cancer patients. Although our study sample was limited in size, the results support further prospective research.     

Effectiveness of an Occupational Therapy Program on Cancer Patients with Dyspnea: Randomized Trial

Abstract

Background: Dyspnea is one of the leading causes of loss of autonomy among patients with advanced cancer. The management of these symptoms relies exclusively on pharmacological measures.

Aims: To assess the effectiveness of a “occupational therapy program” to improve both personal functionality and respiratory function in patients with dyspnea.

Methods: Experimental, prospective, longitudinal, and randomized study. A total of 102 individuals from the inpatient oncology unit of the University Salamanca Hospital Complex were participated in this study. In addition to pharmacological treatment, the intervention group participated in the occupational therapy program.

Results: The study yielded statistically significant differences between the members of the experimental group and those of the control group in functionality levels, as well as statistically significant differences in the BODE global respiratory index scores (p?<?0.001), and in the dyspnea level scores (p?<?0.001) between both groups.

Conclusions: Comprehensive respiratory rehabilitation program from an occupational therapy perspective improve functionality and overall respiratory function levels in cancer patients suffering from dyspnea.     

Personalized Goal for Dyspnea and Clinical Response in Advanced Cancer Patients

Background

The clinical response after comprehensive symptom management is difficult to determine in terms of a clinically important difference. Moreover, therapies should try to reach the threshold perceived by the individual patient for the determination of a favorable response to a treatment.

Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

BackgroundDyspnea is one of the most distressing symptoms encountered by advanced cancer patients. In this study, we aimed to evaluate the role of opioids in the management of cancer-related dyspnea.MethodsA systematic review and meta-analysis based on Randomized Controlled Trials was conducted in the databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials testing the effect of opioids in relieving cancer-related dyspnea. Subgroup and sensitivity analyses were performed to evaluate various types of opioids in dyspnea management and stabilization of the study respectively.ResultsEleven RCTs fulfilled the eligibility criteria and had a total of 290 participants. Nine of these studies were included in meta-analyses. Compared with control, opioid therapy showed a small positive effect in dyspnea, SMD-0.82 (95%CI = ?1.54 to -0.10) and Borg score, WMD-0.95 (95%CI = ?1.83 to -0.06); Opioid therapy did not increase the risk of somnolence, OR0.93 (95%CI = 0.34 to 2.58), whereas a negative effect on respiratory rate was observed,WMD-1.89 (95%CI = ?3.36 to -0.43); Also, there was no evidence to suggest improved performance of the 6MWT test, WMD6.49 (95%CI = ?34.23 to 47.21), or the level of peripheral oxygen saturation, WMD0.33 (95%CI = ?0.59 to 1.24) after opioid therapy. Subgroup analysis yielded a small positive effect for morphine on dyspnea, SMD-0.78 (95%CI = ?1.45 to ?0.10), whereas fentanyl showed no improvement in dyspnea, SMD-0.44 (95%CI = ?0.89 to 0.02). Sensitivity analysis showed no changes in the direction of effect when any one study was excluded from the meta-analyses.ConclusionsOur systematic review and meta-analysis indicated low quality evidence for a small positive effect of opioids in cancer-related dyspnea. Evidence for safety is insufficient as comprehensive adverse events were not adequately reported in studies.     

肺癌脑转移患者安全管理中的预见性护理

目的探讨预防和减少肺癌脑转移患者在住院期间发生安全意外的护理措施。方法采用便利抽样法选取2006年1月至2007年12月某院36例住院肺癌脑转移患者为对照组,实施传统护理方法;同法选择2008年1月至2009年12月某院53例住院肺癌脑转移患者为观察组,实施预见性护理措施。比较两组患者安全意外事件发生情况。结果观察组患者安全意外发生率明显降低,与对照组比较,差异有统计学意义（P〈0.05）。结论预见性护理措施能有效地减少和预防肺癌脑转移患者安全意外的发生,改善患者的生活质量。     

血浆NT-proBNP对急性呼吸困难鉴别意义

目的探讨N末端脑钠肽前体（NT-proBNP）对心源性呼吸困难和肺源性呼吸困难的鉴别价值。方法选择2010年3月～2011年12月住院的呼吸困难患者88例,根据呼吸困难的病因不同,分为心源性组和肺源性组,同时选择健康体检者40名为正常对照组,检测三组血浆NT-proBNP水平,采用超声心动图检测心肺两组患者的左室射血分数、左室舒张末内径、左房舒张末内径。结果心源性组NT-proBNP水平与肺源性组比较,差异有统计学意义（P〈0．05）,心源性组、肺源性组NT-proBNP水平分别与对照组比较,差异均有统计学意义（均P〈0．05）。心源性组左室射血分数和肺源性组比较,差异有统计学意义（P〈0．05）。结论NT-proBNP可作为鉴别心源性呼吸困难和肺源性呼吸困难的一个客观指标,较BNP稳定、可靠,同样可广泛应用于心衰的诊断和危险分层。     

氨基末端脑钠肽前体在急诊呼吸困难患者中的应用

目的:探讨氨基末端脑钠肽前体(NT-proBNP)对急诊呼吸困难患者病因鉴别诊断的临床价值.方法:将我科2009年1月至20011年12月以呼吸困难为主要症状的患者364例分为心源性呼吸困难组(A组,n=178例)和非心源性呼吸困难组(n=186例),比较两组患者血浆NT-proBNP浓度.结果:心源性呼吸困难组NT-proBNP浓度(2994.6±518.2) pg/ml明显高于非心源性呼吸困难组(224.5±67.8) pg/ml,P＜0.01;且NT-proBNP在不同心功能NYHA分级组间呈显著性差异,P＜0.05.结论:床边快速测定血浆NT-proBNP浓度对急诊呼吸困难患者的病因鉴别诊断有较高的应用价值.     

适时翻身替代定时翻身预防临终癌症患者压疮的探讨

目的 探讨适时翻身替代定时翻身预防临终癌症患者压疮效果的异同.方法 调查及分析临终癌症患者采用定时翻身(2 h/次)与适时翻身(＜6 h/次)的患者各40例,比较两组患者出现不适感、压疮发生率、对翻身满意度等.结果 与定时翻身相比,延长翻身间隔时间为6 h内,患者出现疼痛、胸闷、呼吸困难、睡眠不足、烦躁等不适感明显下降(P＜0.0001);但压疮的发生率并未增加(P＞0.05);患者及家属的满意度明显高于定时翻身组(P＜0.05).结论 传统的定时翻身原则不利于临终癌症患者对翻身的耐受,且不符合该类患者的治疗原则,应根据具体情况,在适当的时间给予临终癌症患者翻身.     

Effectiveness of Corticosteroid Treatment in Acute Pharyngitis: A Systematic Review of the Literature

Objectives: The objective was to examine the effectiveness of corticosteroid treatment for the relief of pain associated with acute pharyngitis potentially caused by group A beta‐hemolytic Streptococcus (GABHS). Methods: This was a systematic review of the literature. Data sources used were electronic databases (Cochrane Library, MEDLINE, EMBASE, Biosis Previews, Scopus, and Web of Science), controlled trial registration websites, conference proceedings, study references, experts in the field, and correspondence with authors. Selection criteria consisted of randomized controlled trials (RCTs) in which corticosteroids, alone or in combination with antibiotics, were compared to placebo or any other standard therapy for treatment of acute pharyngitis in adult patients, pediatric patients, or both. Two reviewers independently assessed for relevance, inclusion, and study quality. Weighted mean differences (WMDs) were calculated and are reported with corresponding 95% confidence intervals (CIs). Results: From 272 potentially relevant citations, 10 studies met the inclusion criteria. When compared to placebo, corticosteroids reduced the time to clinically meaningful pain relief (WMD = ?4.54 hours; 95% CI = ?7.19 to ?1.89); however, they provided only a small reduction in pain scores at 24 hours (WMD = ?0.90 on a 0?10 visual analog scale; 95% CI = ?1.5 to ?0.3). Heterogeneity among pooled studies was identified for both outcomes (I² = 81 and 74%, respectively); however, the GABHS‐positive subgroup receiving corticosteroid treatment did have a significant mean reduction in time to clinically meaningful pain relief of 5.22 hours (95% CI = ?7.02 to ?3.42; I² = 0%). Short‐term side effect profiles between corticosteroids and placebo groups were similar. Conclusions: Corticosteroid administration for acute pharyngitis was associated with a relatively small effect in time to clinically meaningful pain relief (4.5‐hour reduction) and in pain relief at 24 hours (0.9‐point reduction), with significant heterogeneity in the pooled results. Decision‐making should be individualized to determine the risks and benefits; however, corticosteroids should not be used as routine treatment for acute pharyngitis. ACADEMIC EMERGENCY MEDICINE 2010; 17:476–483 © 2010 by the Society for Academic Emergency Medicine     

48例结直肠癌手术患者死亡焦虑水平分析

目的分析结直肠癌手术患者死亡焦虑水平。方法 2012年3—9月,采用方便抽样法,对48例结直肠癌手术患者进行死亡焦虑的调查,于入院当日及出院当日,应用中文版死亡焦虑量表进行测量。结果本组患者入院当日的死亡焦虑得分(4.00±2.92),与国外调查结果比较,水平较低(t=3.51,P0.01);患者在害怕痛苦的死去、因想到死亡而困扰等方面表现出焦虑;在条目1、条目7及条目14调查结果存在着性别差异,女性高于男性(P0.05);入院时高死亡焦虑(≥7分)的患者,在出院时死亡焦虑得分下降(P0.05)。结论中文版死亡焦虑量表可用于调查结直肠癌手术患者的死亡焦虑水平,结直肠癌患者的死亡焦虑水平相对于国外研究结果较低;男性患者的一些条目评分低于女性患者;出院时,高死亡焦虑水平的患者比入院时水平降低。但在今后的研究中,应进一步加大样本量,以提供更具代表性的数据支持。     

癌症疼痛的治疗进展

疼痛是癌症病人急需解决的突出问题 ,现就癌症疼痛的治疗进展作一综述     

The Incremental Benefit of a Shortness-of-breath Biomarker Panel in Emergency Department Patients with Dyspnea

Objectives: The objective was to determine the incremental benefit of a shortness-of-breath (SOB) point-of-care biomarker panel on the diagnostic accuracy of emergency department (ED) patients presenting with dyspnea. Methods: Adult ED patients at 10 U.S. EDs with SOB were included. The physician’s estimates of the pretest clinical probability of heart failure (HF), acute myocardial infarction (MI), and pulmonary embolism (PE) were recorded using deciles (0%–100%). Blood samples were analyzed using a SOB point-of-care biomarker panel (troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme [CK-MB], D-dimer, and B-type natriuretic peptide [BNP]). Thirty-day follow-up for MI, HF, and PE was performed. Data were analyzed using logistic regression and receiver operating characteristics (ROC) curve analysis. Results: Of 301 patients, the mean (±standard deviation [SD]) age was 61 (±18) years; 56% were female, 58% were white, and 38% were African American. Diagnoses included MI (n = 54), HF (n = 91), and PE (n = 16) in a total of 129 (43%) of the patients. High pretest clinical certainty (≥80%) identified 60 of these 129 (46.5%) cases. The SOB point-of-care biomarker panel identified 66 additional cases of MI (n = 24), HF (n = 31), and PE (n = 11). The overall adjusted sensitivity for any diagnosis was increased from 65% to 70% with the addition of the SOB point-of-care biomarker panel (difference = 5%, 95% CI = −1.1% to 11%) while specificity was increased from 82% to 83% (difference = 1%, 95% CI = −4% to 7%). The model containing pretest probability and the results of the SOB panel had an area under the curve (AUC) of 83.4% (95% CI = 78.4% to 88.5%), which was not significantly better than the AUC of 80.4% (95% CI = 75.1% to 85.7%) for clinical probability alone. Conclusions: The addition of the SOB panel of markers did not improve the AUC for diagnosing the combined set of clinical conditions. Using the disease-specific SOB biomarkers increased the sensitivity on a disease-by-disease basis; however, specificity was reduced.     

吗啡雾化吸入缓解肿瘤患者癌痛伴暴发性疼痛的效果

目的探讨吗啡雾化吸入缓解肿瘤患者癌痛伴暴发性疼痛(breakthrough pain,BTP;简称暴发痛)的起效时间及效果。方法便利抽样法选择2010年6月至2013年4月上海市第七人民医院肿瘤科收治的89例中重度癌痛患者,按入院先后将其分为观察组45例和对照组44例,两组患者分别采用一次性雾化吸入吗啡和口服即释吗啡缓解疼痛,比较两组患者暴发痛发作未给药剂时、药物起效时、下一次暴发痛发作时的疼痛评分(长海痛尺评定)及不良反应的发生情况。结果观察组患者用药后药物的起效时间为(5.29±0.756)min,短于对照组的(33.86±3.976)min,差异有统计学意义(P0.05);两种治疗方法均能有效缓解癌痛伴随的暴发痛;观察组有4例患者产生不良反应,对照组有16例,差异有统计学意义(P0.05)。结论雾化吸入吗啡具有起效快、效果佳、耐受好、不良反应少等特点,有利于改善肿瘤患者的生活质量。     

肿瘤化疗患者心理需求的调查

目的探讨肿瘤化疗患者的心理需求。方法采用问卷调查形式调查肿瘤化疗患者220例,对患者化疗前、化疗中、化疗后的心理需求进行等级评定。结果肿瘤化疗患者在化疗前、化疗中、化疗后对疾病的心理需求特别需要和需要的总人数均超过全体受调查者的50%。结论护士过硬的技术水平、热情周到的护理服务、及时全面的心理宣教,能够缓解肿瘤化疗患者的不良心理反应,消除其紧张、恐惧心理;同时,应重视健康教育在肿瘤化疗患者中的应用,满足肿瘤化疗患者的心理需求,提高肿瘤化疗患者的生活质量。     

肺癌骨转移放射止痛治疗的临床分析

目的分析36例肺癌骨转移放射治疗止痛效果。方法采用6MV或15MV-X线照射肺癌骨转移患者36例共计50处病灶,常规分割照射32处病灶,照射剂量：21．6-60Gy／12-30次,共3-6周,非常规分割照射18处,照射剂量：29．7-45Gy／3-15次,共1-3周。结果全组50处病灶放疗止痛总有效率92．00％,且与照射总剂量、时间-剂量分割方式、照射部位、原发灶是否行局部治疗、转移灶是单发或多发无关系。起效时间与剂量分割方式有关,非常规分割照射起效快（P-0．0125）。全组有7例患者,计10处病灶在放射期间有疼痛加重．但其发生率与照射方式无关。结论放射治疗肺癌骨转移止痛效果确切,可提高患者生存质量,已成为肺癌骨转移止痛治疗的主要方法。     

晚期肿瘤患者家属对压疮认知的调查分析

目的探讨肿瘤患者家属压疮认知程度的影响因素。方法对2005年5月至2008年12月由院外带来的74例晚期肿瘤压疮患者家属共240人进行护理干预前后压疮认知程度的对照分析。结果文化程度和年龄是家属对压疮认知程度的主要影响因素,护理干预后家属认知程度均有提高,与干预前比较差异有统计学意义（P〈0．05）。结论针对文化程度、年龄等影响因素对家属采取针对性护理干预可以有效减少晚期肿瘤患者压疮的发生率,改善患者生活质量。     

Coping with Symptoms of Dyspnea in Chronic Obstructive Pulmonary Disease

The purpose of this observational study was to determine the relationships between symptoms experienced during episodes of dyspnea, the use of coping strategies, and functional incapacity in patients with chronic obstructive pulmonary disease (COPD). We used a convenience sample of 70 adults enrolled in a pulmonary rehabilitation program in a large, private, Midwestern hospital; 51 (73%) subjects were recruited. The 26 men and 25 women ranged in age from 53 to 83 years. Three standardized self‐report instruments, the Bronchitis‐Emphysema Symptoms Checklist (BESC), the Revised Jalowiec Coping Scale (Part A), and the Functional Incapacitation Scale, were used in participants' homes to collect data. Pulmonary function status (forced expiratory volume in 1 second [FEV₁%]) was determined from chart records; FEV₁% predicted ranged from 17% to 91% with a mean of 39.5%. All subjects reported that their most frequently occurring symptoms during episodes of dyspnea were physiological (shortness of breath, fatigue, and sleep difficulties). The most frequently reported psychological symptoms were helplessness/hopelessness, anxiety, and irritability. Coping styles used most frequently during dyspnea episodes included being optimistic, confrontive, and self‐reliant. The correlation between frequency of symptoms and use of coping strategies was highly significant, r = .354, p = .005. The correlation between frequency of BESC physiologic symptoms and functional status was also highly significant, r = .419, p = .001, as was the correlation between BESC psychological symptoms and functional status, r = .438, p = .001. Nursing interventions are needed to help people with COPD learn strategies for symptom management during episodes of dyspnea.