Nebulized hydromorphone for dyspnea in hospice care of advanced cancer.

This case report describes the use of nebulized hydromorphone for management of dyspnea in advanced cancer in home hospice care. The patient was intolerant of morphine; nebulized hydromorphone was used as an alternative to nebulized morphine for dyspnea and found to be both safe and effective.

Methadone-induced myoclonus in advanced cancer.

Methadone is recommended as being free of some of the neuropsychological side effects noticed with morphine, which are attributed to active metabolites. A patient that received methadone for cancer-associated pain developed myoclonus as a side effect. This has rarely been reported before in the literature. The pathophysiology and management of myoclonus are discussed.

The terminally ill Muslim: death and dying from the Muslim perspective.

Islam holds life as sacred and belonging to God and that all creatures will die one day. Suicide is forbidden. Muslims believe death is only a transition between two different lives. The terminally ill Muslim desires to perform five ritual requirements. Do not resuscitate (DNR) orders are acceptable. A deceased Muslim must always be buried after being ritually washed and wrapped. There are different Muslim schools of thought, but they are united regarding their views on death and dying.

Methylphenidate for fatigue in advanced cancer: a prospective open-label pilot study.

Psychostimulants such as methylphenidate are used for fatigue in cancer patients. We report a prospective, open-label, pilot study of the successful use of methylphenidate to treat fatigue in nine of 11 consecutive patients with advanced cancer. Seven had received radiation or chemotherapy, a median of three weeks (range from one to 30 weeks) prior to methylphenidate. A rapid onset of benefit was noted, even in the presence of mild anemia. Sedation and pain also improved in some. Only one patient had side effects severe enough to stop the medication.

Assessment of delirium in advanced cancer: the use of the bedside confusion scale.

We conducted a prospective assessment of 50 consecutive admissions to an acute palliative medicine unit, using the bedside confusion scale (BSCS). Information including age, gender, diagnosis, and the presence or absence of brain metastasis was collected. Possible predisposing factors for delirium were recorded. Forty-one of 50 consecutive admissions were screened. There were 18 men and 23 women with a median age of 65 years (average: 60-75). The most common diagnoses among all were lung and breast cancer. Thirteen patients were delirious (BSCS score of > or = 2), 10 borderline (BSCS score = 1), and 21 normal (BSCS score = 0). Brain metastases and drugs appeared to be the most common predisposing factors of delirium. Forty percent of those that were delirious received haloperidol as symptomatic treatment. The BSCS is simple, portable, valid, quick, and easy to use by any medical team member. Delirium is common in hospitalized patients with advanced cancer.

A phase II study of methylphenidate for depression in advanced cancer.

UNLABELLED: This study evaluated the use of methylphenidate for depression in advanced cancer DESIGN: Phase II open-label prospective study. ELIGIBILITY CRITERIA: No previous use of methylphenidate or current use of other antidepressants. EVALUATION: Depression and response to treatment were determined by asking the patient: "are you depressed?" Patients were assessed at baseline and at days 3, 5, and 7. TREATMENT: Starting dose was 5 mg at 8:00 a.m. and 12:00 noon. The dose was titrated for lack of response on any of the assessment days. RESPONSE CRITERIA: A negative response to the question: "are you depressed?" RESULTS: Some 41 patients were enrolled and 30 (15 men, 15 women) completed the study. Median age was 68 years (range: 30-90). Methylphenidate was stopped for six patients because of side effects and five were not evaluable; 21 responded to 10 mg/day on day 3; the other nine responded to 20 mg/day on day 5, 29 maintained their positive response through day 7. Anorexia, fatigue, concentration, and sedation also improved in some. All who completed the study had tolerable side effects, none of which caused treatment to stop. CONCLUSIONS: Methylphenidate is effective for depression in advanced cancer A starting dose of 10 mg in divided doses is effective in most patients. Dose escalation may be needed. Improvement occurs within three days. Close monitoring of side effects is recommended.

Evaluation and treatment of cancer-related fluid deficits: volume depletion and dehydration.

Fluid deficits should be divided into two categories (dehydration and volume depletion) according to pathophysiology and into 3 categories (hyponatremic, hypernatremic, and isotonic) according to the plasma sodium concentration. Dehydration (total water deficit especially intracellular) is always hypernatremic, while volume depletion (intravascular water and sodium deficit) is either hyponatremic, hypernatremic, or isotonic. There are no clear clinical differences among the various categories, but a delay of capillary refill, tachycardia, and orthostatic hypotension are more common with early volume depletion. An Evans blue and mannitol test can be used to distinguish between hypernatremic volume depletion and dehydration. Careful clinical assessment and laboratory tests (especially serum sodium) are the key to diagnosis and effective management. According to the type (hypernatremic, hyponatremic, or isotonic), severity of fluid deficit, and associated symptoms, oral or parenteral fluid should be given along with treatment of the underlying cause. In hemodynamically compromised individuals with orthostatic hypotension and oliguria, replacement with isotonic saline until hemodynamic stabilization is crucial. Terminal hydration is still controversial. Important ethical principles govern clinical decision-making about hydration at the end of life.

Hydromorphone: pharmacology and clinical applications in cancer patients.

Hydromorphone is a more potent opioid analgesic than morphine and is used for moderate to severe pain. It can be administered by injection, by infusion, by mouth, and rectally. Oral bioavailability is low. The kidney excretes hydromorphone and its metabolites. Some metabolites may have greater analgesic activity than hydromorphone itself but are unlikely to contribute to the pharmacological activity of hydromorphone. With the exception of pruritus, sedation and nausea and vomiting, which may occur less after hydromorphone than after morphine, the side-effects of these drugs are similar. On a milligram basis hydromorphone is five times as potent as morphine when given by the oral route, and 8.5 times as potent as morphine when given intravenously.

Bioelectrical impedance, cancer nutritional assessment, and ascites.

This report describes our experience in the use of bioelectrical impedance analysis (BIA) as a method of nutritional assessment in a cancer patient with ascites. The BIA was an unreliable measure of body composition in this setting.

Evaluation of nutritional status in advanced metastatic cancer.

Consecutive cancer referrals to a palliative medicine program were evaluated to assess nutritional status using a standard protocol. The study included 352 patients (180 men, 172 women; median age 61 years, range 22-94 years). The most common diagnosis was lung cancer. All had metastatic disease, 139 with gastrointestinal involvement. The most common gastrointestinal symptoms were weight loss ( n=307), anorexia ( n=285), and early satiety ( n=243). Of those with any weight loss, 71% had lost >or0% of their pre-illness weight. The most common factor identified which might have contributed to weight loss was hypophagia ( n=275/307). Men had lost weight more often and to a greater extent than women. Triceps skinfold (TSF) was measured in 337: 51% had values that suggested severe fat deficiency. Upper mid-arm muscle area (AMA) was measured in 349: 30% had evidence of significant muscle mass reduction. The body mass index (BMI) was normal or increased in most patients. Calculated resting energy expenditure (REE) ( n=324) was high in 41%. C-reactive protein was elevated in 74% of those measured ( n=50). We conclude that: (1).most of this group of cancer patients referred to palliative medicine had severe weight loss; (2).there was a gender difference in the severity and type of weight loss; (3).males lost more weight overall and more muscle than females; (4).males with any degree of weight loss had a higher REE than females; (5).a significant correlation existed between the time from diagnosis to death and the severity of weight loss in the prior month; (6).BMI was normal in most patients, suggesting precancer diagnosis obesity; and (7).both TSF and AMA correlated well with body composition of both fat and protein as determined by bioelectrical impedance.