Improvement of Restless Legs Syndrome Under Treatment of Cancer Pain With Morphine and Fentanyl.

Restless-Legs-Syndrome (RLS), also known as Willis-Ekbom disease, is a sleep- and rest related disorder characterized by the unpleasant urge to move the legs. Pharmacological therapy is mainly based on dopamine-agonists and delta-2-alpha calcium channel ligands. Also, randomized-controlled-trials (RCTs) reported effectiveness of oral oxycodone (in combination with naloxone), and intrathecal opioids have also been administered for this indication. In the case reported here, a patient with advanced pancreatic cancer was referred to an acute palliative care unit for the treatment of cancer-related pain. Yet, in thorough exploration of her symptom burden, the patient reported that she felt her quality of life had been predominantly limited by symptoms other than cancer pain. Her medical history and neurological examination revealed that these symptoms were most obviously caused by severe RLS. In the years before, pharmacological therapies with dopamine-agonists and delta-2-alpha calcium channel ligands were initiated, but failed to relieve the RLS. In the palliative care ward, intravenous morphine was successfully titrated to treat her cancer pain. Concurrently, the patient also experienced almost complete relief from her RLS-symptoms and an increase in quality of life. The amelioration of her RLS-symptoms continued after morphine therapy was switched from intravenous to oral administration. Even after the patient was dismissed to home care and opioid rotation to transdermal fentanyl, symptom control of RLS remained excellent. To our knowledge, this is the first report of successfully treating RLS with intravenous and oral morphine. Since morphine is more easily available worldwide and the cost of morphine therapy is substantially lower compared to oxycodone/naloxone, comparisons to morphine may be an intriguing option for future RCTs.

Early Palliative Care: Pro, but Please Be Precise!

BACKGROUND: By definition, palliative care (PC) is applicable already in early stages of incurable and life-threatening diseases, in conjunction with therapies that are intended to prolong life, such as for example chemo- or radiotherapy. Many patients suffer from distressing symptoms or problems in early phases of such illness. Therefore, it is not a question of "if" PC should be integrated early into oncology, but "how." General PC is defined as an approach that should be delivered by healthcare professionals regardless of their discipline. This is often referred to as "general" or "primary" PC. For this, routine symptom assessment, expertise concerning basic symptom management, and communication skills are basic requirements. Communication skills include the willingness to engage in discussions concerning patients' fears, worries and end-of-life issues without the fear of destroying hope. Specialist PC is provided by specialist teams regardless of the patients' disease, be it cancer or non-cancer. Such teams should be integrated in the care of PC patients depending on the availability of these services and the patients' needs. Key messages: "Early PC" must not be used synonymously with "early specialist PC" because much of the PC is delivered as basic oncology PC. For the integration of specialist PC, the identification of triggers is warranted in different institutions to facilitate a meaningful and effective cooperation. Such cooperations should be based on patients' needs, but must also account for questions of availability and resources.

[Palliative Care - not just for the final phase. A rewiev of evidence]. / Palliative Care: Nicht erst am Lebensende ­ eine praxisorientierte Diskussion der aktuellen Evidenz.

Palliative Care - not just for the final phase. A rewiev of evidence Abstract. Already in early stages of their disease, patients with incurable, advanced cancer and non-cancer disease suffer from a range of limitations of their quality of life due to symptoms (i. e. pain, dyspnoea) or psychical, social or spiritual problems. Palliative Care aims to maintain the patients' quality of life and is applicable already early in the disease trajectory and not only at the end of life. As providers of general (basic) palliative care, all health care providers from all disciplines should therefore hold basic expertise in symptom control and communication. Also, they should be aware of psychical, social and spiritual dimensions of suffering. The integration and cooperation of health care services should be driven by the actual needs and demands of the individual patient. In addition to general palliative care, specialist palliative care is provided by multi-professional teams, for example, as specialist palliative home care teams or palliative care services in hospitals. In the future, it will be paramount to routinely identify patients with complex needs and severe (symptom) burden who will benefit most from early integration of specialist palliative care.

[Delirium in Palliative Care: Evidence and Practice]. / Das Delirante Syndrom in der Palliative Care: Frische Evidenz und alte Weisheiten.

Delirium in Palliative Care: Evidence and Practice Abstract. Delirium is a frequent condition in Palliative Care. For patients, their families and the formal caregivers it is associated with substantial burden, fears and challenges. It is also associated with increased morbidity and mortality and often irreversible. Of utmost importance is the identification of patients and threat for delirium and prophylactic measures to avoid delirium whenever possible. For this, risk factors should be identified and eliminated whenever possible. The correct identification of delirium is challenging and especially the hypoactive form of delirium is often unrecognised. When delirium is diagnosed, the etiology must be explored thoroughly and potentially reversible causes should be treated and eliminated whenever feasible and appropriate. The pharmacologic therapy is based on benzodiazepines and neuroleptics. Yet, the use of the substances should be restricted to severe psychotic episodes of the hyperactive form of delirium. It is of utmost importance to know that "disorientation", "restlessness" or delirium alone are no indication for pharmacotherapy. Recently two landmark randomized controlled clinical trials concerning pharmacotherapy for delirium in palliative care have been published. This review presents a practical overview of the prevention, diagnosis and therapy of delirium in palliative care alongside the presentation and discussion of the recently published trials.

EffenDys-Fentanyl Buccal Tablet for the Relief of Episodic Breathlessness in Patients With Advanced Cancer: A Multicenter, Open-Label, Randomized, Morphine-Controlled, Crossover, Phase II Trial.

CONTEXT: Episodic breathlessness is a frequent and burdensome symptom in cancer patients but pharmacological treatment is limited. OBJECTIVES: To determine time to onset, efficacy, feasibility, and safety of transmucosal fentanyl in comparison to immediate-release morphine for the relief of episodic breathlessness. METHODS: Phase II, investigator-initiated, multicenter, open-label, randomized, morphine-controlled, crossover trial with open-label titration of fentanyl buccal tablet (FBT) in inpatients with incurable cancer. The primary outcome was time to onset of meaningful breathlessness relief. Secondary outcomes were efficacy (breathlessness intensity difference at 10 and 30 minutes; sum of breathlessness intensity difference at 15 and 60 minutes), feasibility, and safety. Study was approved by local ethics committees. RESULTS: Twenty-five of 1341 patients were eligible, 10 patients agreed to participate (four female, mean age 58 ± 11, mean Karnofsky score 67 ± 11). Two patients died before final visits and two patients dropped-out because of disease progression leaving six patients for analysis with 61 episodes of breathlessness. Mean time to onset was for FBT 12.7 ± 10.0 and for immediate-release morphine 23.6 ± 15.1 minutes with a mean difference of -10.9 minutes (95% CI = -24.5 to 2.7, P = 0.094). Efficacy measures were predominately in favor for FBT. Both interventions were safe. Feasibility failed because of too much study demands for a very ill patient group. CONCLUSION: The description of a faster and greater relief of episodic breathlessness by transmucosal fentanyl versus morphine justifies further evaluation by a full-powered trial.

Malignant melanoma S3-guideline "diagnosis, therapy and follow-up of melanoma".

This first German evidence-based guideline for cutaneous melanoma was developed under the auspices of the German Dermatological Society (DDG) and the Dermatologic Cooperative Oncology Group (DeCOG) and funded by the German Guideline Program in Oncology. The recommendations are based on a systematic literature search, and on the consensus of 32 medical societies, working groups and patient representatives. This guideline contains recommendations concerning diagnosis, therapy and follow-up of melanoma. The diagnosis of primary melanoma based on clinical features and dermoscopic criteria. It is confirmed by histopathologic examination after complete excision with a small margin. For the staging of melanoma, the AJCC classification of 2009 is used. The definitive excision margins are 0.5 cm for in situ melanomas, 1 cm for melanomas with up to 2 mm tumor thickness and 2 cm for thicker melanomas, they are reached in a secondary excision. From 1 mm tumor thickness, sentinel lymph node biopsy is recommended. For stages II and III, adjuvant therapy with interferon-alpha should be considered after careful analysis of the benefits and possible risks. In the stage of locoregional metastasis surgical treatment with complete lymphadenectomy is the treatment of choice. In the presence of distant metastasis mutational screening should be performed for BRAF mutation, and eventually for CKIT and NRAS mutations. In the presence of mutations in case of inoperable metastases targeted therapies should be applied. Furthermore, in addition to standard chemotherapies, new immunotherapies such as the CTLA-4 antibody ipilimumab are available. Regular follow-up examinations are recommended for a period of 10 years, with an intensified schedule for the first three years.