Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey.

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Psychiatric problems in returning travelers: features and associations.

BACKGROUND: Travelers may return from the tropics with psychological problems. The literature regarding features and associations of these psychological problems is limited. METHODS: Case histories of 15 consecutive returning travelers seen at our psychiatric service during the last 8 years. RESULTS: The median age of this group was 25 years, 10 were males, and the length of trip ranged from 10 days to 8.5 months. None of these travelers had prior psychopathology. The most common presentation was anxiety (with or without depression, n = 11), 3 suffered from acute psychosis, and 1 had pure depression. Eight of the travelers have used illicit drugs, which in 5 cases probably served as a trigger. Antimalarials may have played a role in 3 travelers. Six travelers needed antidepressants and supportive therapy, 3 neuroleptics, and 1 psychotherapy. These treatments lasted for 6 months and over in 6 of the travelers. CONCLUSION: Psychiatric problems among travelers to the tropics are multifarious in nature, multifactorial, have a strong relation to drug abuse, and may require a long and intensive therapy. Travelers should be better educated about the risks of using illicit drugs.

Octreotide in the treatment of severe chemotherapy-induced diarrhea.

BACKGROUND: Chemotherapy-induced diarrhea (CID) is a common side effect of a number of chemotherapeutic agents. Conventional therapy for severe CID with opioids or loperamide is moderately effective. A prospective trial was conducted using octreotide acetate for treatment of severe CID refractory to loperamide. PATIENTS AND METHODS: Thirty-two patients with grade 2 and 3 CID refractory to loperamide were treated with octreotide at a dosage of 100 microg subcutaneously 3x/day for three days followed by 50 microg 3x/day for three days. Previous chemotherapy consisted of regimens containing fluorouracil, leucovorin, CPT-11, cyclophosphamide, methotrexate and cisplatin. Primary tumors were colorectal (n = 23), gastric (n = 3), and other cancers (n = 6). RESULTS: Complete resolution of diarrhea was obtained in 30 of 32 patients (94%); 5 within 24 hours, 14 within 48 hours, and 11 within 72 hours of treatment. Nineteen patients were treated as outpatients. Thirteen were hospitalized for a median of three days. Response was unaffected by age, gender, performance status, previous chemotherapy or primary tumor site. No side effects related to octreotide were observed. CONCLUSIONS: Octreotide 100 microg subcutaneously 3x/day for three days is an effective, safe treatment for CID given primarily or as a second-line therapy after loperamide failure.

Severe symptomatic hyponatremia during citalopram therapy.

Hyponatremia secondary to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is an uncommon complication of treatment with the new class of antidepressant agents, the selective serotonin reuptake inhibitors (SSRIs). Most of the reported cases were associated with fluoxetine; only 2 have previously been described in association with citalopram. We describe an elderly woman who presented with severe symptomatic hyponatremia caused by the SIADH during therapy with citalopram. Because the use of SSRIs is becoming more popular among elderly depressed patients, the present case and the other 2 reported previously emphasize the need for greater awareness of the development of this serious and potentially fatal complication also in association with citalopram therapy and suggest that serum sodium levels should be monitored closely in elderly patients during treatment with citalopram.

Gemcitabine-induced radiation recall dermatitis: case report.

A 65-year-old male with lung adenocarcinoma received radiotherapy to the mediastinum and right upper lobe, followed by chemotherapy with gemcitabine. Radiation recall dermatitis developed in the area corresponding to the radiotherapy portal. This is one of just a few cases reported recently concerning radiation recall dermatitis stemming from gemcitabine.

Neuropsychiatric problems in 2,500 long-term young travelers to the tropics.

BACKGROUND: The prevalence and features of travel associated neuropsychiatric problems (NPP) and their relation to previous psychological consultations, antimalarials and recreational drug use have not been adequately studied. METHODS: A two-phase postal and telephone survey has been conducted among 2,500 young travelers to tropical countries. We measured the rate and duration of NPP, characterized their features, and their association with previous psychological profiles, itinerary, type of travel, consumption of recreational drugs, and malaria prophylaxis. RESULTS: First phase: Out of 1,340 respondents, 151 (11.3%) indicated that they had NPP during travel, in contrast with 2.3% who needed psychological consultation before travel (p<.001). Second phase: 117 of 151 responded to the study questionnaire. The mean age of the respondents was 24.4 years, 54.7% were female, and the mean stay abroad was 5.3 months. The most common NPP were sleeping disturbances (52.1%), fatigue (48.7%) and dizziness (39.3%). Thirty-three travelers (2.5%) had severe symptoms, and 16 (1.2%) had symptoms lasting more than 2 months. Seven travelers had pure or mixed depressive symptoms. Consumption of recreational drugs was admitted by 22.2%. Mefloquine was used significantly more often by those who suffered NPP, than by the entire cohort (98.2% vs. 70.7%; p<.001). CONCLUSIONS: Long-term travel to the tropics was associated, in this cohort, with a considerable rate of neuropsychiatric symptoms. The majority of the responding travelers were females, used mefloquine as prophylaxis, and at least one fifth used recreational drugs.

Ambience in the endoscopy room has little effect on patients.

With hopes of alleviating discomfort and improving the tolerance of patients undergoing endoscopy, we have assessed the influence of various background conditions in the endoscopy room. Two hundred twenty-one candidates for upper endoscopy were randomly allocated to four groups, each with one of the following conditions in the endoscopy room: background music and conversation related to the patient's complaints (n=50); background music and conversation unrelated to the patient (n=53); background music only, with the staff maintaining silence (n=49); and complete silence (n=47). Before endoscopy patients answered a 26-item questionnaire that included an evaluation of their degree of anxiety before the examination. Conscious sedation was induced by using 3 mg midazolam. After complete recovery from sedation, patients answered another set of questions. Patients in all four groups felt quite comfortable with the atmosphere in which gastroscopy was performed. Neither music, conversation, nor silence had a great effect on patients as far as improving tolerance or diminishing anxiety. Therefore, endoscopists and nurses may have a free hand in choosing the prevailing conditions during the examination. This conclusion may be valid for both patients and the staff involved in other invasive procedures performed under light sedation.

[Combined treatment of hepatic tumors by cryosurgery and resection: first results].

Cryosurgery is an old technique which is being used for hepatic tumors as an adjuvant to hepatic resection. We recently treated 7 patients with multiple malignant liver tumors, 5 of whom had colorectal metastases, 1 carcinoid metastases, and 1 multiple hepatic lesions of hepatocellular carcinoma. 6 underwent combined liver resection and cryoablation of lesions in the remaining liver. In the 7th patient, only cryoablation was performed because hepatic resection was rejected and there was an extrahepatic metastasis. The advantages of this treatment are removal or destruction of all liver lesions found by any method, including intraoperative ultrasound examination, maximal preservation of normal liver parenchyma and that it is curative in patients inoperable by standard criteria.

Severe humoral hypercalcemia in primary isolated non-Hodgkin's lymphoma of the heart.

The etiology of hypercalcemia was investigated in a patient with primary isolated non-Hodgkin's lymphoma of the heart. There was no evidence of bone involvement, and parathyroid hormone and calciterol levels were suppressed. Plasma parathyroid-hormone-related protein (PTHrP 1-86) detected by immunoradiometric assay was increased (15 pmol/l compared with < 0.3 pmol/l in a control). We demonstrated that PTHrP was the humoral mediator of severe hypercalcemia in our patient.

Plasmapheresis in neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is a severe and potentially fatal reaction to neuroleptic drugs. Treatment requires withdrawal of the neuroleptic agent, metabolic and cardiovascular support, physical cooling and treatment with dantrolene sodium and bromcriptine mesylate. We report a therapeutic success of plasmapheresis in a case of neuroleptic malignant syndrome in which conventional therapy had failed. We postulate that plasmapheresis may prove to be a useful tool in treating this frequently fatal disease.

[Psychological aspects of cochlear implantation].

Psychological aspects of cochlear implantation were studied in 20 adults and children. Patients were interviewed before admission and were given tests and questionnaires to answer with regard to overall wellbeing, intellectual functioning, hopes and beliefs, expectations with regard to the implant and the support they were getting (last 2 also for a family member). Those who passed the screening were referred for surgery, and those who didn't were referred for therapy. 6 months after implantation the patient and the family member were again interviewed and answered questionnaires with regard to adjustment to the implant and the patient's satisfaction with it. In those who benefitted from the implant there were no psychopathological features, there was good cognitive functioning, a moderate level of concentration and attention span and a great degree of flexibility in personality traits. Crucial to better adjustment was quality of family support. Following cochlear implantation there was considerable improvement in life style.

The effect of in vitro irradiation on human NK cell activity. A preliminary report.

Natural killer activity of peripheral blood cells was evaluated after in vitro irradiation at doses ranging between 100 and 1600 cGy. Natural killer (NK) cells from normal donors exhibited a trend towards increased cytotoxicity peaking at about 600 cGy and then gradually decreasing. NK cells isolated from peripheral blood of cancer patients showed a lower baseline of activity, which was less affected by the same doses of in vitro irradiation. A distinction could be made between patients with early disease and those with advanced cancers; patients with early cancers showing NK activity close to that of normal donors.

Does a detailed explanation prior to gastroscopy reduce the patient's anxiety?

The object of this study was to investigate the assumption that a detailed explanation and description of gastroscopy to a patient reduces his fears of the procedure. In order to check this assumption, 243 consecutive patients who underwent elective gastroscopy were randomly distributed to 4 groups: Group A received a standard brief description of upper G-I endoscopy by the treating physician; Group B patients were given a detailed description by the endoscopist himself; Group C was given a comprehensive explanation and was shown an album of pictures illustrating each stage of the procedure; Group D saw a specially prepared video film of the procedure. A fifth group, E, consisted of patients who had previously undergone upper gastrointestinal endoscopy. Patient anxiety was measured using the "Spielberger State and Trait Anxiety Scales". According to the scoring on these scales there was no significant difference between the groups, thus showing that increasingly detailed description of the procedure did not diminish patients' fear. Neither did ethnic background or age have any significant influence on these results. Higher education had marginal influence on patients' apprehension about the procedure. However, female patients had significantly higher anxiety state and trait anxiety scoring than men. If endoscopy can be taken as typically representative of all invasive procedures, these results may have a much more general application.