Refractory cancer pain in young child at end-of-life: Can we alleviate the suffering?

Pain is a common and highly distressing symptom in children with advanced malignancies and it is often multifactorial at the end-of-life. The prognosis of cancer pain is reported to be worse in those with mixed pain type, high pain severity, daily opioid use, and poor emotional well-being. We describe a case of 13-year-old boy, known case of metastatic Ewing sarcoma right iliac bone, who presented to our palliative care ward with intractable pain and was finally discharged home for terminal care with high doses of morphine, ketamine, and midazolam infusion through elastomeric pump attached to a peripherally inserted central catheter (PICC line). The suffering of imminently dying children should be reduced, and judicious dose escalation of opioids along with adjuvants is appropriate and often necessary.

Effect of the stellate ganglion block on symptoms of ulcerative colitis: A case report.

RATIONALE: Chronic ulcerative colitis is an autoimmune disease in which epithelial injury continuously occurs in the colonic mucosa. While mesalazine (5-aminosalicylic acid) is used to treat ulcerative colitis, it can also cause liver failure, headaches, and abdominal pain; therefore, an alternative treatment is required. The purpose of this study was to evaluate the effectiveness of 80 stellate ganglion blocks in reducing pain and other symptoms in a patient with chronic ulcerative colitis. PATIENT CONCERNS: A 54-year-old female patient with a history of ulcerative colitis was concerned with worsening symptoms, such as abdominal discomfort and bloody-mucous stools, over the past 3 years. DIAGNOSES: Oozing mucosal bleeding and a small amount of exudate were observed on colonoscopy; a diagnosis of ulcerative colitis was made upon histologic examination. INTERVENTIONS AND OUTCOMES: A total of 80 stellate ganglion blocks were administered, after which the patient's symptom and pain level was decreased from 6 to 4 points on the numeric rating scale (11-point, 0 = no pain, 10 = worst pain imaginable). Improved clinical signs were observed on colonoscopy at a follow-up assessment. LESSONS: The stellate ganglion block may be effective for the reduction of pain and other symptoms in patients with chronic ulcerative colitis.

Patient-controlled analgesia and morphine consumption in sickle cell anemia painful crises: A new protocol.

OBJECTIVES: The sudden and rapidly increasing severity of pain in sickle cell anemia painful crises frequently requires the use of strong opioids. Patients require continuous administrations of various doses (increased/decreased) within the following hours. This study aims to retrospectively evaluate the effects of a structured protocol based on standardized Visual Analogue Scale (VAS) and Patient-controlled analgesia (PCA) patient demand count on morphine consumption in painful crises. METHODS: A total of 177 painful crises of 93 patients who were administered morphine using the PCA method according to appropriate analgesia protocol between 2004-2018 were evaluated in this study. The demographic data, hemoglobin chromatography and genotypes, painful episode follow-up time, VAS scores before and after treatment, and daily morphine consumption of the patients were recorded. Morphine consumption during the crisis according to age groups and sex were compared. RESULTS: Of the patients, 57% were homozygous hemoglobin type SS (HbSS). Mean morphine consumption with PCA method was 56.9±35.4 mg (min-max: 10-232 mg) and mean follow-up time was 3.4±2.1 days (min.-max.: 1-11). VAS scores were significantly lower after treatment (6.8±2.3 pre-treatment; 0.8±0.6 post-treatment) (p<0.05). CONCLUSION: To our knowledge, our study is the first structured protocol based on VAS and PCA demand data. We believe lower morphine dosage using PCA protocol according to the rapidly changing pain levels of the patients will provide effective analgesia. Prospective studies with fewer limitations will more effectively demonstrate the effectiveness of this protocol.

Erector Spinae Block for Chest Trauma in Aeromedical Prehospital and Retrieval Medicine.

Pain management for patients with chest trauma in aeromedical prehospital and retrieval medicine is important in order to maintain respiratory function. However, it can be challenging to achieve with opioids alone due to side effects including sedation, respiratory depression, and nausea.Reported are two trauma patients with uncontrolled pain despite multiple doses of opioids managed with a single-injection erector spinae plane block (ESB).The sono-anatomy and performance of the block, indications, and possible complications associated with the ESB are described.An ultrasound-guided ESB is useful for multimodal pain therapy following chest trauma in aeromedical retrieval medicine.

[An evaluation of palliative care service effect in patients with cancer diagnosis: Comparison in terms of the symptom level and care satisfaction]. / Kanser tanili hastalarda palyatif bakim hizmetlerinin etkisinin degerlendirilmesi: Semptom düzeyi ve bakim memnuniyeti açisindan bir karsilastirma.

OBJECTIVES: The aim of this study was to evaluate the effect of palliative care on the symptom level assessment and satisfaction of patients diagnosed with cancer. METHODS: The study was carried out with 60 cancer patients who received service at a palliative care center (PCC) and 59 cancer patients who received general care services at a public hospital. The effect of the services provided at the 2 hospitals was evaluated using the Edmonton Symptom Assessment System and the European Organisation for Research and Treatment of Cancer In-patient Satisfaction with Care Questionnaire. The data were analyzed to determine number and percentage distributions, the significance of differences between 2 peers, and 2-way analysis of variance in repetitive measurements. RESULTS: It was determined that the symptom severity of the PCC patients was greater. In a 1 week interval, greater improvement was observed in all of the symptoms of the patients who received general care, and the evaluation revealed a statistically significant difference between the hospitals in terms of fatigue, nausea, and dyspnea (p<0.05). However, the mean satisfaction of the patients who received services at the PCC was higher, and the difference in the general satisfaction level between hospitals was statistically significant (p<0.05). CONCLUSION: The palliative care provided to cancer patients at the PCC was less effective in reducing symptom levels compared with the results from patients of general care at a public hospital, but provided greater patient satisfaction.

[Effective pain therapy can improve the survival of patients with pancreatic cancer]. / Etkin agri tedavisi pankreas kanserli hastalarda sagkalimi artirabilir.

OBJECTIVES: In this study, characteristics and analgesic treatment of patients with pancreatic cancer who applied to the algology clinic were evaluated. METHODS: Demographic characteristics, pathologic diagnosis, metastasis, cancer treatment, and analgesic interventions in 60 patients with pancreatic cancer, referred to the algology clinic, were examined. RESULTS: The application time of the patients to the clinic was 3.9+-0.92 months after the diagnosis, and the visual analog scale (VAS) was 6.96+-0.11 at the initial assessment. According to the analgesic step ladder protocol, a nonopiod + weak opioid + strong opioid (transdermal) were applied in 58.33%, a nonopioid + weak opioid + strong opiod (oral) in 5%, and nonopiod + weak opioid in 36.66% of the patients. Adjuvant pain medications were used in 68.33% of the patients (benzodiazepine, 80.48%; antidepressant, 19.51%), while no adjuvant was used in 31.66% of the patients. While the mean survival time for patients with pancreatic cancer changed from 3 to 6 months, it was 8.48+-7.46 months for patients who applied to the pain clinic. CONCLUSION: Abdominal pain in pancreatic cancer is the most common symptom that negatively affects the quality of life. A good analgesia improves the survival, while pain decreases the survival. The results of the present study demonstrated that the survival of the patients with metastatic pancreatic cancer who received effective pain therapy in the algology clinic may be longer.

Cannabis in palliative care: current challenges and practical recommendations.

Pain and symptom control challenges are common in palliative care, and the search for other therapeutic strategies is ongoing. Unfortunately, patients and their caregivers are receiving little information or support from healthcare providers regarding the increasingly popular cannabinoid-based medicines (CBM). Clinicians, meanwhile, feel understandably perplexed by the discrepancy between the available evidence and the rapid interest in which patients and their families have demonstrated for CBM. There is an urgent need to address the many challenges that are delaying the appropriate integration of CBM into clinical practice, notwithstanding the obvious need for a solid general knowledge of pharmacology, mechanism of action and available clinical evidence supporting its use. The authors will address these challenges and provide practical recommendations regarding patient assessment for the use of CBM. The authors will also make suggestions regarding patient expectations in order to define clear objectives, review the necessary precautions prior to initiating treatment, aid in selecting the appropriate strain and route of administration as well as establishing proper titration and monitoring protocols. The authors will also discuss the lesser known but potentially therapeutic psychoactive effects of cannabis. As this class of therapeutic agents are likely to play a major role in palliative medicine in the near future, clinicians would benefit from familiarizing themselves with CBM and we can expect that patients and their caregivers will appreciate receiving support in their search for safe and effective therapeutic alternatives.

Effects of relaxing therapies on patient's pain during percutaneous interventional radiology procedures.

BACKGROUND: Interventional radiology procedures in cancer patients cause stress and anxiety. Our objective was to relate our experience in the use of sophrology techniques during interventional radiology procedures and evaluate the effects on patient's pain and anxiety. METHODS: We present a prospective observational study on 60 consecutive patients who underwent interventional radiology procedures in a context of oncologic management from September 2017 to March 2018. Forty-two patients were asked if they wished to benefit from the sophrology and hypnosis techniques during their procedure. A control group was also made including 18 patients. Anxiety level and pain were evaluated using the visual analog scale (VAS) before and during procedures. RESULTS: We observed a significant decrease in anxiety experienced by patients during interventional radiology procedures compared to before procedures in the sophrology group (P=3.318E-08), and a level of anxiety and pain during gestures inferior to that of the control group (P=2.035E-06 and 7.03E-05 respectively). CONCLUSIONS: Relaxing therapies, such as sophrology and hypnosis, seems to be an interesting additional tool for the management of patients in interventional oncology, inducing a decrease of stress, pain, and anxiety in patients.

A Randomized, Single-Blind Study Evaluating the Effect of a Bone Pain Education Video on Reported Bone Pain in Patients with Breast Cancer Receiving Chemotherapy and Pegfilgrastim.

BACKGROUND: Mild-to-moderate bone pain is the most commonly reported adverse event associated with pegfilgrastim. AIMS: To investigate the effect of bone pain education on pegfilgrastim-related bone pain in patients with breast cancer receiving chemotherapy and pegfilgrastim. DESIGN: Randomized, single-blind study. SETTINGS: Forty-eight community oncology clinics throughout the United States. PARTICIPANTS: Three hundred women ≥18 years of age with newly diagnosed stage I -III breast cancer, who were planning ≥4 cycles of neoadjuvant or adjuvant chemotherapy with pegfilgrastim support starting in cycle 1. METHODS: Patients were randomized 1:1 to view a general education DVD on chemotherapy side effects (GE-DVD) or a DVD on bone pain following chemotherapy and pegfilgrastim (BP-DVD). Patients recorded severity of bone pain on a scale of 0-10, location of pain, and use of bone pain medications (i.e., analgesics, antihistamines, and nonsteroidal anti-inflammatory drugs) for 5 days, beginning on the day of pegfilgrastim administration, in each of the first four chemotherapy cycles. RESULTS: Patient-reported maximum bone pain was similar in the two groups (GE-DVD vs BP-DVD: cycle 1, 3.2 vs. 3.5, p = .3479; across all cycles, 4.1 vs. 4.6, p = .2196). Other measures of bone pain were also similar between the groups. Bone pain was highest in cycle 1 but decreased and then remained stable in subsequent cycles. Bone pain medication use was similar in both groups and was highest in cycle 1. CONCLUSIONS: The bone pain-specific education evaluated here did not improve perceptions of bone pain reported in this patient population.

The Effect of the Pain Symptom Cluster on Performance in Women Diagnosed with Advanced Breast Cancer: The Mediating Role of the Psychoneurological Symptom Cluster.

BACKGROUND: Pain, depression, anxiety, sleep disturbances, and constipation were reported in different symptom clusters at different stages of breast cancer. Managing symptom clusters rather than individual symptoms can improve performance status. AIM: The study examined the effect of pain symptom cluster (pain and constipation) on performance when mediated by the psychoneurological symptom cluster (depression, anxiety, and sleep disturbances) using age as a moderator. DESIGN: A secondary analysis. SETTINGS: Palliative care center at a tertiary medical center in northeast Ohio. PARTICIPANTS: Eighty-six women diagnosed with advanced breast cancer. METHOD: A quantitative cross-sectional approach. RESULTS: Ordinal logistic regression showed that pain symptom cluster did not have a significant mediation effect on performance. Odds ratio indicated that subjects with pain symptom cluster were 63% more likely to be bedridden (odds ratio = 1.63, confidence interval = .69-3.84). Women who reported pain symptom cluster were 5% more likely to have psychoneurological symptom cluster (odds ratio = 1.05, confidence interval = .400-2.774). Stratified analysis of age showed no differences in performance. Post-hoc analysis showed that the components of pain symptom cluster had a significant effect on psychoneurological symptom cluster (odds ratio: 3 [1.18-7.62]). CONCLUSIONS: Pain, constipation, depression, anxiety, and sleep disturbances were highly prevalent in women with advanced breast cancer. However, they tended to cluster in different symptom clusters. Although some findings were not significant, they all supported the direction of the tested hypotheses. Variations in symptom clusters research, including methodology, instruments, statistical tests, and chosen symptom cluster correlation coefficient, should be addressed.

Consultation for total pain in high-risk obstetrics.

Palliative care (PC) consultation rarely takes place in the clinical setting of high-risk obstetrics, where 'total pain' may be undermanaged. Here, we present a case of a young woman carrying twins and hospitalised for acute abdominal pain. Workup for her pain revealed non-viable fetal tissue positioned in the uterine horn; the remaining fetus was viable. Initial attempts to control the patient's pain with strong parenteral opioids by the obstetrics team and the acute pain service failed. The PC service was consulted to assist. Applying a customary interdisciplinary approach in a novel PC clinical setting, the PC service was able to identify and attend to the patient's physical, psychosocial and spiritual pain, resulting in an overall decrease in reported pain scores, decreased opioid requirement and a plan for preservation of the viable fetus.

Challenging equipotency calculation for hydromorphone after long-term intravenous application.

In advanced stages, most cancer patients suffer from pain which can usually be well controlled following the World Health Organization (WHO) level scheme. While the majority of patients report adequate pain relief by strong opioids (WHO III), some require an opioid rotation. Despite the existence of conversion tables, these rotations mea lead to inadequate pain control or life threatening events. Here, we report about a patient with urothelial cell carcinoma presenting in our Department of Pain Medicine with massive pain aggravation up to NRS values of 10/10 despite administration of the highest dose of intravenously applied hydromorphone. After a small single dose of the far less potent opioid piritramide with exceptionally good response, we conducted a stepwise opioid rotation from hydromorphone to piritramide within one week without any signs of abstinence or withdrawal. After the opioid rotation, we discharged the patient nearly free of pain with piritramide doses far less than equianalgesic dose tables would have recommended. Our report impressively points out that even after long-term intravenous application of highly potent opioids, new titrations are necessary for rotation to avoid overdosage and discusses several mechanisms underlying individual response to different opioids.

Quality of life in responders after palliative radiation therapy for painful bone metastases using EORTC QLQ-C30 and EORTC QLQ-BM22: results of a Brazilian cohort.

BACKGROUND: Bone metastases cause pain, suffering and impaired quality of life (QoL). Palliative radiotherapy (RT) and/or chemotherapy are effective methods in controlling pain, reducing analgesics use and improving QoL. This study goal was to investigate the changes in QoL scores among patients who responded to palliative treatment. METHODS: A prospective study evaluating the role of radiation therapy in a public academic hospital in São Paulo-Brazil recorded patients' opioid use, pain score, Portuguese version of QLQ-BM22 and QLQ-C30 before and 2 months after radiotherapy. Analgesic use and pain score were used to calculate international pain response category. Overall response was defined as the sum of complete response (CR) and partial response (PR). CR was defined as pain score of 0 with no increase in analgesic intake whereas PR was defined as pain reduction ≥2 without analgesic increase or analgesic reduction in ≥25% without increase in pain at the treated site. RESULTS: From September 2014 to October 2015, 25 patients with bone metastases responded to RT or chemotherapy (1 CR, 24 PR). There were 8 male and 17 female patients. The median age of the 25 patients was 59 (range, 22 to 80) years old. Patient's primary cancer site was breast [11], prostate [5], lung [2], others [7]. For QLQ-BM 22, the mean scores of 4 categories at baseline were: pain site (PS) 39, pain characteristics (PC) 61, function interference (FI) 49 and psycho-social aspects (PA) 57. At 2 month follow up, the scores were PS 27, PC 37, FI 70 and PA 59. Statistical significant improvement (P<0.05) was seen in PS, PC, FI but not PA. In the QLQ-C30, the scores were not statistically different for all categories, except for pain that demonstrated a 33 point decrease in the median pain score domain (66 to 33). CONCLUSIONS: Responders to RT at 2 months presented improvement in BM22 and C30 pain domains, and also improvement in functional interference domain of the BM22 questionnaire.

Development of a mHealth Real-Time Pain Self-Management App for Adolescents With Cancer: An Iterative Usability Testing Study [Formula: see text].

PURPOSE: A user-centered design approach was used to refine the mHealth Pain Squad+ real-time pain self-management app for adolescents with cancer for its usability (defined as being easy to use, easy to understand, efficient to complete, and acceptable). METHOD: Three iterative usability testing cycles involving adolescent observation and interview were used to achieve this objective. During each cycle, adolescents used the app while "thinking aloud" about issues encountered. Observed difficulties and errors were recorded and a semistructured interview about the experience was conducted. Using a qualitative conventional content analysis approach, themes related to app usability were identified. RESULTS: Participants required an average of 4.3 minutes to complete the pain assessment component of Pain Squad+. Overall, the app was acceptable. Problematic issues related to software malfunction, interface design flaws, and confusing text. Software revisions were made to address each issue. CONCLUSION: The multifaceted usability approach used provided insight into how a real-time app can be made acceptable to adolescents with cancer and succeeded in developing a Pain Squad+ app that is fit for future effectiveness testing.

Initial single center experience: radiofrequency ablation assisted vertebroplasty and osteoplasty using a bipolar device in the palliation of bone metastases.

BACKGROUND: To assess the safety and clinical outcomes of bipolar radiofrequency ablation (RFA) assisted vertebroplasty (VP) and osteoplasty (OP) in pathological and insufficiency fractures. The insufficiency fractures were in patients who sustained demineralization secondary to cancer treatment. METHODS: Patients referred for symptomatic malignant or insufficiency fractures for VP or OP from January 2011 to May 2015 were retrospectively reviewed. Bipolar RFA was performed (Osteocool RF ablation system, Baylis Medical) reaching a constant temperature of 70 ℃ over 7 to 15 minutes followed by cement injection. Clinical outcomes were evaluated by review of the electronic medical record (EMR). Radiological outcomes were assessed with CT. Pre and post procedural pain scores were also documented for the RFA subset, primarily to see if there were any adverse effects when using RFA on pain relief. RESULTS: Twenty-six patients in the study were treated with the RFA assisted technique. These contributed to 4 OPs and 35 VP levels. Of these four VP levels were insufficiency fractures. All were technically successful without morbidity or mortality. Fifty-six patients were treated with a non RFA assisted technique. All these were VPs and 142 levels were treated in total. Two levels in this subset were insufficiency fractures. All were technically successful without morbidity or mortality. There was a significantly reduced rate of posterior and venous cement leaks when RFA was used prior to VP. There was no difference in the rate of leakage into the disc spaces when comparing RFA assisted to the conventional technique. Pain scores in the RFA assisted group decreased significantly post procedure with no unanticipated neuropathic events. CONCLUSIONS: RFA assisted VP and OP using a bipolar device is safe and allows for controlled injection of cement into a preformed thermal cavity with a significant decrease in venous and posterior cement leaks. Rate of cement leakage into the disc spaces was unaffected.

Efficacy of single fraction conventional radiation therapy for painful uncomplicated bone metastases: a systematic review and meta-analysis.

BACKGROUND: Single fraction radiotherapy (SFRT) and multiple fraction radiotherapy (MFRT) are effective for painful uncomplicated bone metastases and have been shown to be of similar efficacy. The optimal conventional external beam SFRT dose for maximum pain relief remains uncertain. The aim of this systematic review was to comprehensively review and synthesize overall pain response rates by dose. METHODS: A literature search was conducted in Ovid MEDLINE(R) (1946 to June 2016 week 3), Embase Classic & Embase (1947 to 2016 week 26) and Cochrane Central Register of Controlled Trials (May 2016) using keywords such as bone metastases, radiotherapy and single fraction (SF). RESULTS: The 635 results from the search were screened, and ultimately 27 were included for quantitative synthesis. The review indicated that 10 and 6 Gy may produce superior overall response (OR) and complete response (CR) rates compared to 8 Gy, and 6 Gy may result in better partial response (PR) than 8 Gy. However, only a few studies documented doses other than 8 Gy. In trials that directly compared 8 Gy to 4 Gy or 6 Gy, 8 Gy was deemed statistically superior. CONCLUSIONS: 8 Gy SFRT was the most commonly administered dose for palliation of bone metastases supporting its efficacy and safety. Future studies should explore the efficacy of 10 Gy while minimizing its side effects.

Overcoming the challenges associated with symptom management in palliative care.

End of life (EOL) care is a topic that many families have difficulty discussing. A number of families are uncomfortable with accepting the fact that death is a part of every human's reality. Ideas and thoughts of death are interpreted differently across various cultures, and lacking to discuss disease trajectory and what to expect down the road with a physician, brings forward conflict during EOL care. Let us consider the complexities of treating Mr. X who is an 80-year-old male of Italian background with a history of advanced lung cancer with metastasis to the brain. He was recently diagnosed and his health began to rapidly decline at home. Mr. X is used in this case study to explore the challenges in providing care in a palliative care unit (PCU), and the ways in which we can overcome them.