A review of the safety and efficacy of inhaled methoxyflurane as an analgesic for outpatient procedures.

Methoxyflurane delivered via a hand-held inhaler is a proven analgesic which has been used in Australasia for emergency relief of trauma associated pain since the 1970s. The agent is self-administered by the patient under the supervision of trained personnel. More than 5 million patients have received inhaled methoxyflurane without significant side effects. Methoxyflurane is also licensed in Australasia for the relief of pain in monitored conscious patients requiring analgesia for minor surgical procedures. Recent clinical studies undertaken in a variety of outpatient settings, including colonoscopy, prostate biopsy, dental procedures, bone marrow biopsy, and the management of burns dressings, indicate that inhaled methoxyflurane has significant analgesic activity, without producing deep sedation or respiratory depression. Return to full psychomotor activity is rapid. Thus, methoxyflurane may be a suitable and well-tolerated alternative to traditional i.v. sedative agents for outpatient medical and surgical procedures. There are direct advantages to the patient in terms of rapid recovery and an early return to normal activities, and significant benefits for outpatient departments in terms of cost saving and rate of throughput. Further randomised controlled trials comparing the efficacy, safety, and cost-effectiveness of inhaled methoxyflurane against traditional i.v. sedative techniques are currently in progress.

Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine.

BACKGROUND: An adequately powered, double-blind, multisite, randomised controlled trial has shown no net clinical benefit for subcutaneous ketamine over placebo in the management of cancer pain refractory to combination opioid and co-analgesic therapy. The results of the trial were disseminated widely both nationally and internationally. AIM: To determine whether the trial had impacted on clinical practice in Australasia. METHODS: Members of the Australia and New Zealand Society of Palliative Medicine were sent an online ketamine utilisation survey. RESULTS: A total of 123/392 clinicians responded (31% response rate). The majority of respondents had practised for more than 10 years in a metropolitan hospital setting. Ketamine had been prescribed by 91% of respondents, and 92% were aware of the trial. As a result, 65% of respondents had changed practice (17% no longer prescribed ketamine, 46% used less and 2% more). Thirty-five per cent had not changed practice. Reasons for change included belief in the results of the study, concerns over the toxicity reported or because there were alternatives for pain control. Of those who prescribed less, over 80% were more selective and would now only use the drug in certain clinical situations or pain types, or when all other medications had failed. CONCLUSIONS: Although two-thirds of respondents reported practice change as a result of the randomised controlled trial, a minority remained convinced of the benefit of the drug from their own observations and would require additional evidence.

Patient reporting and doctor recognition of dyspnoea in a comprehensive cancer centre.

The aim of this study was to examine different aspects of dyspnoea in an Australian acute cancer care population, specifically prevalence, recognition, reporting, symptom control methods and prognostic significance. Patients and treating hospital medical officer were concurrently asked to evaluate the experience of dyspnoea. The prevalence of dyspnoea was 33%, with discrepancies observed between patient and doctor reporting of the presence of dyspnoea (P = 0.021), as well as its intensity and distress. Symptomatic methods for the relief of cancer-related dyspnoea are underused, particularly opioids. The medical underestimation of dyspnoea is consistent with previous studies and potentially detracts from effective management of this symptom.

Community-based palliative care for Bangladeshi patients in east London. Accounts of bereaved carers.

The aim of this paper is to describe the palliative care experience of Bangladeshi patients and carers in the Tower Hamlets area in the east of London. Semi-structured interviews were carried out in Sylheti, the Bengali dialect of this community, with bereaved primary carers of 18 patients (10 male, eight female) referred to an east London community palliative care team between 1986 and 1993. It was found that patients were young, with a mean age of males of 55 years (range 34-65) and females of 40 years (range 28-57). Communication difficulties were common. The fluency in English of patients was low, with reliance on family members, especially children, for translation. The diagnosis was known by all patients, but only 56% of carers agreed with disclosure. Team dissatisfaction with communication was recorded in 16 cases. Fourteen patients died in London; however, 13 were buried in Bangladesh. Carers often reported symptoms as poorly controlled. Pain was said to be severe for 14 patients, and pain control said to be poor in 11. Family and friends provided most support during the illness and bereavement. Serious financial difficulties occurred in nine families. General practitioners were involved actively in six cases. In conclusion, there are ethno-specific needs in this particular community, many of which arise from socio-economic factors, recent migration and religious beliefs, and which are highlighted by terminal illness.

A comparison of the use of sedatives in a hospital support team and in a hospice.

This study examines how frequently and for what indications sedatives are prescribed in a hospital support team and in a hospice. We also looked at the survival of sedated patients from the date of admission and from the start of sedation. Overall 26% of patients were prescribed sedatives in order to sedate them (31% at the hospice and 21% at the hospital) and 43% of patients were given sedatives for symptom control (67% at the hospice and 21% at the hospital). Sedated patients survived for a mean of 1.3 days after the start of sedation, and there was no detectable difference in survival from the date of admission between sedated and nonsedated patients.