What are Palliative Care Physicians for Adults Taught on Palliative Care for Children? Paediatric Aspects in Palliative Care Curricula for Adults.

BACKGROUND: Children suffering from life limiting diseases are frequently cared for by adult palliative care teams due to missing paediatric structures in that field. However it is questionable whether palliative care curricula for physicians comprehensively cover issues of paediatric palliative care (PaedPC). AIM: To identify all PaedPC issues included in inter-professional or medical palliative care curricula (PCC) and to evaluate the breadth and quality of PaedPC issues covered in these curricula. DESIGN: Inter-professional or medical palliative care curricula (PCC) were identified by an extensive literature review in German and English using the search-engines Google as well as Medline, MedPilot and Pubmed. RESULTS: Worldwide 30 PCC were identified, with only 15 curricula mentioning any PaedPC issues. Of those 15 curricula, up to 22 PaedPC topics were highlighted in each. In 10 or more PaedPC following topics were highlighted: grief and bereavement in family, parents and siblings; communication with children; paediatric malignancies; pain management in PPC and pharmacology. In the majority of PCC curricula where PaedPC issues were identified the following topics were mentioned- grief and bereavement in the family, parents and siblings, communication with children, paediatric malignancies, paediatric pain management and pharmacology. CONCLUSIONS: The variability of inclusion of PaedPC issues and the lack of depth and standardisation of knowledge, skills and attitudes in PaedPC issues included in PCC curricula is not sufficient to guide adult palliative care physicians in their clinical work with children suffering from life limiting diseases.

[Implementation of intersectional field 13: a survey of medical faculties in Germany]. / Implementierung des Querschnittsbereichs 13: Umfrage an den medizinischen Fakultäten in Deutschland.

BACKGROUND: In 2013 palliative medicine (PM) will be integrated into the undergraduate curriculum as part of the mandatory education in German medical universities. The aim of this study is to determine the current state of implementation at German medical faculties (MF). METHODS: All German MFs were contacted using a written postal survey in June 2012. RESULTS: A total of 32 out of 36 MFs participated. Teaching staff consists of 15 or more lecturers in 8 MFs (30 %) and includes psychologists in 24 MFs (75 %) and also nurses in 18 MFs (56 %). Participating physicians are specialized in anesthesiology, internal medicine and general medicine. Teaching staff include palliative outpatient (20 MFs, 63 %) and consultation services (22 MFs, 69 %). Bedside teaching is provided in 15 MFs (47 %). Multiple choice tests are the major form of assessment (29 MFs, 84 %). The total number of teaching units in PM is between 12 and 43 and is usually provided at the end of medical school education. Nurses are employed in the education significantly more in MFs with a chair in PM. General practitioners were engaged only by faculties without a chair in PM. CONCLUSIONS: The implementation of the mandatory training in PM at MFs in Germany is inhomogeneous. Further steps include in particular the development of a competence-based curriculum and assessment.

[Pain management in international curricula for undergraduate education in palliative medicine. A palliative education assessment tool (PEAT) analysis]. / Schmerztherapeutische Inhalte internationaler Curricula für die studentische Lehre in der Palliativmedizin. Eine PEAT-basierte Analyse.

BACKGROUND: In the context of undergraduate medical education, there is the question of overlap between palliative medicine and pain management. International curricula for palliative medicine were analyzed with regard to the content concerning pain management. METHODS: Available international curricula were sought through general search engines (Google, Medline/Pubmed) in the German and English languages. The palliative care education assessment tool (PEAT), a validated instrument for curricula mapping, was used for detection of pain management content. The PEAT comprises 7 domains and 83 objectives. Domain II (pain) contains 12 items (15%). Additional pain management content was analyzed qualitatively. RESULTS: Between 1993 and 2011 16 international curricula for undergraduate education in palliative medicine were identified and every curriculum contained PEAT-domain II (pain). Altogether, 2-65 out of 83 PEAT objectives and 0-11 specific pain-related PEAT objectives were included as learning content. Hence, the latter define 0-21% of the contents of the analyzed curricula. The only additional topic was "breakthrough pain" which was mentioned in 4 out of 16 curricula. CONCLUSIONS: Pain-related objectives are regularly mentioned in international undergraduate palliative medicine curricula. The extent is limited and therefore the concordance to general pain management is low.

[Circadian rhythm of PCA-based opioid consumption in children with chemotherapy-related mucositis]. / Zirkadianer Rhythmus des PCA-gesteuerten Opioidverbrauchs bei Kindern mit chemotherapiebedingter Mukositis.

BACKGROUND: In order to match the interindividual and intraindividual differences in opioid requirements of pediatric oncology patients with mucositis, patient-controlled analgesia (PCA) seems to be the optimal pain therapy option, but scientific data are lacking. METHOD: A retrospective chart review of PCA-treated children with mucositis was carried out over a 6-year period (2000-2006) at the university hospital for children in Erlangen. RESULTS: The median age of the patients was 12.6 years and they mainly suffered from forms of acute leukemia. Daily morphine equivalent dose (MED) requirements increased with the start of the PCA therapy from 14.5 mg/day to 18.7 mg/day (p=0.021; Wilcoxon test). Children required more opioids by bolus request during the night (10:01 p.m. to 06:00 a.m.; 6.28 mg; 13%) than during the other 8-hour intervals (06:01 a.m. to 02:00 p.m. and 02:01 p.m. to 10:00 p.m.; both 21.3 mg (43.5%) during the whole 10-day study period. In 8 out of 10 days there was a significant diurnal variation in opioid requirement with significantly lower requirement during the night (p<0.05 Friedman test). The median count of delivered and un-delivered bolus requests during the night was 0-1 and 0, respectively. CONCLUSION: PCA seems to be an ideal, dependable and feasible mode of analgesic administration for the individual titration of dose in children with chemotherapy-induced mucositis. This is expressed through the increase in daily self-administered opioid doses after starting PCA, the huge interindividual variability in opioid consumption and the rare event of an un-delivered bolus request during lock-out time. With the use of a background infusion, additional bolus requests are rare during the night.

Peripheral electrophysiological responses decrease in response to repetitive painful stimulation of the human nasal mucosa.

The study aimed to investigate the relation of both negative mucosal potentials (NMP) obtained from respiratory epithelium, and pain ratings to repetitive stimulation with CO2 (21 subjects). Trains of four stimuli of identical intensity (70% v/v) were applied at a constant interseries interval (approximately 60 s) but different interstimulus intervals (ISI) of 2 s or 6 s. At an ISI of 6 s, ratings decreased while they increased at an interval of 2 s (P < 0.01). This change was accompanied by the buildup of burning pain probably relating to the 'wind-up' of spinal neurons. In contrast, the decrease of NMP amplitudes was stronger the shorter the ISI (P < 0.01). These findings are in line with the view that the NMP reflects activation of epithelial nociceptors (C-fibers and/or A delta-fibers).

Peripheral and central nervous changes in patients with rheumatoid arthritis in response to repetitive painful stimulation.

It has been observed that patients with rheumatoid arthritis (RA) respond differently to repetitive painful stimulation. The present study investigated whether this is related to the peripheral or central nervous nociceptive system. EEG-derived potentials and the negative mucosal potential (NMP) from the respiratory epithelium were recorded in response to painful intranasal stimulation with gaseous CO(2). Differences between groups (12 RA patients, 12 controls) were found when stimuli were presented at short intervals. While the NMP did not differ between groups, patients had larger cortical responses to the first stimuli of a series of painful stimuli. This may indicate that in RA central nervous changes of nociceptive processing are present.

Rhythmic pattern of PCA opioid demand in adults with cancer pain.

INTRODUCTION: Patient-controlled analgesia (PCA) has an established role in managing postoperative pain and has been successfully used in-patients with cancer pain. The variation of opioid requirement over a 24h period for patients with cancer pain is debated with suggestions of reduced need over night. METHODS: Retrospective review of 10years (1997-2006) data of all in-patients with cancer pain treated with strong opioids delivered by PCA. RESULTS: 141 patients with cancer pain had a mean cumulative 10day morphine equivalent dose per patient of 671mg (median 470mg; range 10-2170mg). At night (10:01pm to 06:00am) the patient's self administered less bolus doses (69mg, (25%)) than during the other two 8h periods (06:01am to 02:00pm, 91mg (33%) and 02:01pm to 10:00pm, 116mg (42%)). In 8 out of 10days a significant variation in bolus requests was observed with significantly less bolus requests during the night (Friedman test, p<0.05). Furthermore, the median number of delivered bolus requests per patient, at night, was 2-3 compared to the morning and afternoon periods of 3-7 and 3.5-6, respectively. CONCLUSION: PCA met individual patient's opioid needs in a safe and effective manner despite a large inter-individual variability in opioid consumption. Moreover, the study indicated a pattern of less opioid requirement at night.

[Patient-controlled analgesia (PCA) in outpatients with cancer pain. Analysis of 1,692 treatment days]. / Patientenkontrollierte Analgesie (PCA) bei ambulanten Tumorschmerzpatienten. Analyse von 1692 Behandlungstagen.

INTRODUCTION: In the home-care setting, cancer pain patients in need of parenteral analgesia have to be switched to patient-controlled analgesia using portable pumps. But there is a paucity on data on the logistic requirements or the success rate of such a cost-intensive therapy performed by specialized home-care services. METHODS: In a retrospective study we analyzed data on care intensity, logistics and outcome of 46 consecutive palliative cancer patients with patient-controlled analgesia (PCA) in a home-care setting. RESULTS: On days 1, 2, and 3 of PCA the switch to parenteral analgesia resulted in a significant increase of the median daily opioid dose in comparison to the dose just prior to PCA. Concurrently, pain scores were significantly reduced. The median duration of PCA was 25 days (range 2-189 days). On average, each patient was seen by the home-care team every 7.4 days. The median duration of the home visits was 60 min (range, 10-190 min). Of the visits 20% were unscheduled, most of these visits being due to problems regarding analgesia. Most patients died at home. Insufficient analgesia required prefinal hospitalization in only a single case. CONCLUSION: If the indications are correct, intravenous PCA for palliative cancer pain patients results in higher opioid consumption and better pain control. Home-care PCA requires a lot of human and financial resources, but pain-related hospitalization can be prevented.

[Practical pain control in pediatric oncology. Recommendations of the German Society of Pediatric Oncology and Hematology, the German Association for the Study of Pain, the German Society of Palliative Care, and the Vodafone Institute of Children's Pain Therapy and Palliative Care]. / Praktische Schmerztherapie in der pädiatrischen Onkologie. Empfehlungen der Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH), der Deutschen Gesellschaft zum Studium des Schmerzes (DGSS), der Deutschen Gesellschaft für Palliativmedizin (DGP) und des Vodafone-Stiftungsinstituts für Kinderschmerztherapie und Pädiatrische Palliativmedizin an der Vestischen Kinder- und Jugendklinik Datteln -- Universität Witten/Herdecke (IKP).

In pediatric oncology, optimal pain control is still a challenge. A structured pain history and the regular scoring of pain intensity using age-adapted measuring tools are hallmarks of optimal pain control. Psychological measures are as important as drug therapy in the prophylaxis or control of pain, especially when performing invasive procedures. Pain control is oriented toward the WHO multistep therapeutic schedule. On no account should the pediatric patient have to climb up the "analgesic ladder" - strong pain requires the primary use of strong opioids. Give opioids preferably by the oral route and by the clock - short-acting opioids should be used to treat breakthrough pain. Alternatives are i.v. infusion, patient-controlled analgesia, and transdermal applications. Constipation is the adverse effect most often seen with (oral) opioid therapy. Adverse effects should be anticipated, and prophylactic treatment should be given consistently. The assistance of pediatric nurses is of the utmost importance in pediatric pain control. Nurses deliver the basis for rational and effective pain control by scoring pain intensity and documenting drug administration as well as adverse effects. The nurses' task is also to prepare the patient for and monitor the patient during painful procedures. It is the responsibility of both nurse and doctor to guarantee emergency intervention during sedation whenever needed. In our guideline we comment on drug selection and dosage, pain measurement tools, and documentation tools for the purpose of pain control. Those tools may be easily integrated into daily routine.

[Long-term pediatric opioid based pain control. Case reports]. / Opioidtherapie chronischer Schmerzen bei Kindern. Fallbesprechungen.

Based on 4 case reports we focus on the peculiarities of long-term pediatric opioid based pain control. Case report #1, emphasizing the importance of adequate opioid dosing with reference to body weight, illustrates that with adequate management oral sustained-release opioid therapy is safe even in infants less than one year old. Case report #2 is the first report on the usage of buccal fentanyl citrate for pediatric break-through pain control. Case report #3 focuses on the adverse effects of opioid pain control in an infant with neurological impairment. Case report #4 reports on the successful tumor pain control using transdermal buprenorphine. We conclude that proven therapeutic strategies for opioid pain control as applied in adults may be adopted for the usage on children in pediatrics. However, it is mandatory to take into account both the pharmacokinetic and pharmacodynamic peculiarities of childhood.