RESUMO
AIM: Of the work: evaluation of a multidisciplinary strategy and a prospective medicosurgical protocol for the treatment of occlusion due to unresectable peritoneal carcinomatosis. PATIENTS AND METHODS: All the included patients had occlusion and intraabdominal carcinomatosis. None could benefit a curative treatment. 75 patients were included for 80 episodes of intestinal obstruction. The protocol involved three successive therapeutic phases. (i) Treatment during five days by corticosteroids associated to antiemetic agents, anticholinergic antisecretory agents, and analgesics as needed (Phase I); (ii) In the event of refractory occlusive symptoms treatment by somatostatin analog during 3 days (phase II); (iii) If this treatment was ineffective a gastrostomy was performed (phase III). RESULTS: Median survival was 31 days. Outcome showed that for the 80 episodes of obstruction, phase I medical treatment enabled relief in 50 cases (63%) and phase II medical treatment (somatostatin) enabled relief in 11 cases (14%). 10 more patients (13%) were relieved by the gastrostomie and one by a duodenal endoprothesis. Symptom control without a long-term nasogastric tube was achieved for 72 of the 80 episodes (90%). Fifty-eight episodes (72% of overall total) were controlled for 10 days or less. Median time to gastrostomy was 17 days. Eight patients experienced persistent vomiting and required a nasogastric aspiration until death. CONCLUSION: This multidisciplinary approach between Palliative Care and Specialized Medical and Surgical teams enabled relief of the occlusive symptoms for 90% of the patients of the study. The protocol was useful for the caregivers for the management of terminally ill patients. To enhance these results, it would be necessary to shorten the delay of relief, which has been longer than ten days for one third of the patients. The simplification of the protocol including two steps instead of three is on study.
Assuntos
Carcinoma/complicações , Obstrução Intestinal/etiologia , Obstrução Intestinal/cirurgia , Cuidados Paliativos , Neoplasias Peritoneais/complicações , Corticosteroides/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos/uso terapêutico , Antieméticos/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Estudos Prospectivos , Análise de Sobrevida , Assistência Terminal , Resultado do TratamentoRESUMO
OBJECTIVE: The end-point of this survey was to evaluate the number of patients in advanced or terminal phase of a life-threatening disease and hospitalised in the university hospital in Grenoble on a given day. The secondary end-points were determination of the profile of patients undergoing palliative care and the therapeutic charge they represented for the hospital in order to develop optimal medico-psycho-social responses adapted to the needs of this population, their family and friends and the teams of health professionals who treat them. METHODS: The survey was based on a questionnaire including 106 items and one open question, filled-in by a physician and the nurses of the hospital, together with the interviewer. RESULTS: Out of the 1495 patients hospitalised in the hospital centre (84% occupation), 114 patients were included in the study, i.e., 8% of the total number of patients present. Patients' mean age was of 70 (21Assuntos
Cuidados Paliativos
, Doente Terminal
, Adolescente
, Adulto
, Idoso
, Idoso de 80 Anos ou mais
, Distribuição de Qui-Quadrado
, Coleta de Dados
, Interpretação Estatística de Dados
, França
, Hospitalização
, Hospitais Universitários
, Humanos
, Pessoa de Meia-Idade
, Inquéritos e Questionários
, Organização Mundial da Saúde
RESUMO
PURPOSE: The new opioids and the new galenic forms, now available in France, require an update in practitioners' knowledge. The purpose of the present study is to help those prescribing select the appropriate opioid and its galenic form for pain relief. CURRENT KNOWLEDGE AND KEY POINTS: Presentation of pharmacological properties of opioids (mechanisms, pharmacokinetics and pharmacovigilance). Presentation of indications, modes of prescription and use of main opioids for pain (especially cancer pain). Examples for calculating required drug dosage depending on the clinical situation and the route of administration. Symptomatic treatments of the main undesirable side effects of the opioids, and actions to be taken in the event of accidental overdose. FUTURE PROSPECTS AND PROJECTS: Oral morphine is the treatment first recommended for nociceptive pain insufficiently relieved by WHO level I and II analgesics. The new immediate-release galenic forms allow morphine titration and the treatment of breakthrough pain. Transmucosal fentanyl, soon available in France, is recommended for breakthrough pain in patients already under opioid treatment: it gives more rapid relied starting after only 5 minutes and it only acts for a short time. Transdermal fentanyl is indicated for stable cancer pain. It is particularly suitable when oral and injectable morphine routes are not available, or for patients with severe constipation. Hydromorphone is the first opioid recommended in France for severe cancer pain when morphine resistance exists or uncontrolled side effects are present (opioid rotation). The new opioids and the new galenic forms widen the range of therapeutic possibilities. Their use is well codified for cancer pain and must still undergo clinical trials for chronic non-cancer pain. When correctly indicated, opioid selection provides a considerable advance in pain management.
Assuntos
Analgésicos Opioides/uso terapêutico , Dor/tratamento farmacológico , Administração Oral , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/farmacologia , Ensaios Clínicos como Assunto , Preparações de Ação Retardada , Fentanila , Humanos , Hidromorfona/efeitos adversos , Hidromorfona/farmacologia , Hidromorfona/uso terapêutico , Morfina/efeitos adversos , Morfina/farmacologia , Morfina/uso terapêutico , Neoplasias/complicações , Organização Mundial da SaúdeRESUMO
This multicentre, randomized double-blind study was undertaken to assess the efficacy of corticosteroids as a palliative treatment of intestinal obstruction due to advanced and incurable cancer. Thirty-one French palliative care units agreed to participate in the study and 12 actually recruited at least one patient. To be included, patients had to have an advanced cancer with a surgically inoperable bowel obstruction and to have received no specific anticancer therapy within the preceding 28 days. They had to fulfil at least three of the following criteria: vomiting at least twice a day; colicky abdominal pain; no flatus for 12 h or more; no stool for at least 4 days, faecal impaction being excluded; intestinal distension; air-fluid levels or absence of gas in the colon on an abdominal radiograph. Patients were randomized in three groups to receive either a placebo for 3 days (group A), or methylprednisolone 240 mg daily for 3 days (group B) or methylprednisolone 40 mg daily for 3 days (group C). Symptoms were assessed daily but success or failure of the treatment was assessed on day 4, according to the disappearance or persistence of symptoms. Fifty-eight patients were randomized, of whom 52 were able to be evaluated. Details of symptoms and associated treatments are described below. Of 40 patients without a nasogastric tube, symptoms were relieved in 68% of cases versus 33% among placebo-treated patients (P = 0.047). In 12 patients who had a nasogastric tube already in place, the results are less significant (60% versus 33% with P = 0.080). Because of the small sample size, no conclusions can be reached about the relative efficacy of low versus high-dose treatment regimes.
Assuntos
Anti-Inflamatórios/uso terapêutico , Neoplasias Intestinais/tratamento farmacológico , Obstrução Intestinal/tratamento farmacológico , Metilprednisolona/uso terapêutico , Cuidados Paliativos , Adulto , Idoso , Método Duplo-Cego , Feminino , Humanos , Neoplasias Intestinais/complicações , Obstrução Intestinal/complicações , Obstrução Intestinal/patologia , Masculino , Pessoa de Meia-Idade , Assistência TerminalRESUMO
The aims of myocardial revascularisation are to treat angina, reduce ischaemia and improve life expectancy. Patients with multivessel disease have a poor prognosis, especially when the lesions are proximal, when the preseptal left anterior descending artery is involved and when left ventricular dysfunction is present. In this particular group of patients, coronary bypass surgery has been shown to improve 10 year survival. Coronary angioplasty has been compared with surgical treatment in many clinical trials. The medium-term survival is the same in both groups, but with a higher number of repeat procedures except in diabetic patients in whom mortality is higher after angioplasty. The use of coronary stents should reduce the number of post-angioplasty procedures. Constant technical improvements, the introduction of surgery without cardiopulmonary bypass, combined revascularisation procedures, new antiplatelet drugs, the absence of long-term comparative results, all this results in a personalized choice of revascularisation procedure based on the overall clinical and angiography features of each particular case.
Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Doença das Coronárias/cirurgia , Doença das Coronárias/terapia , Revascularização Miocárdica/métodos , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Prognóstico , Stents , Análise de Sobrevida , Resultado do TratamentoRESUMO
To test the large number of hypotheses proposed as causes for childhood leukemia, a case control study was carried out on every child diagnosed for acute leukemia between 1.1.1977 and 12.31.1982, under the age of 15 and living in the region of Lyon (Rhône-Alpes and Saône-et-Loire). Some factors could not be confirmed, possibly in relation with the relatively small sample size (208 cases). Others were confirmed, especially the excess of incidence among 2 to 4 year old children and those belonging to higher socioeconomic groups. Two new factors were identified: the age of the father (over 40 years at child birth) and the profession of the father (manipulation of meat in the few years prior the diagnosis of leukemia in the child).
Assuntos
Meio Ambiente , Leucemia/etiologia , Doença Aguda , Adolescente , Criança , Pré-Escolar , Exposição Ambiental , Feminino , França , Humanos , Lactente , Recém-Nascido , Leucemia/epidemiologia , Leucemia/genética , Masculino , Idade Paterna , Estações do Ano , Fatores SocioeconômicosAssuntos
Neoplasias Cardíacas/diagnóstico , Mixoma/diagnóstico , Valva Tricúspide , Cateterismo Cardíaco , Criança , Ecocardiografia , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/patologia , Humanos , Masculino , Mixoma/diagnóstico por imagem , Mixoma/patologia , Radiografia , Valva Tricúspide/cirurgiaRESUMO
The case of a 6 year old child with a tricuspid valve myxoma is presented. Early diagnosis by echocardiography, confirmed by angiography, resulted in surgical cure before any symptoms appeared. This is the only reported echocardiographic study of a myxoma inserted on the tricuspid valve found in a review of the literature of 6 cases of right ventricular myxoma. The tricuspid valves were found to be thickened and prolapsed into the right atrium. The amplitude of excursion of the anterior leaflet was greatly increased, its mass projecting into the right ventricular outflow tract in diastole and remaining there until the end of right ventricular ejection. The echocardiographic signs localising the precise origin of the tumor in the tricuspid valve are developed. The differential diagnosis with right atrial myxoma prolapsing into the ventricular cavity, benign and malignant right ventricular tumours and tricuspid valve vegetations is discussed. The precision of the diagnostic information obtained by echocardiography suggests that angiography may not be essential any longer, especially when the risk of embolisation and acute obstruction are taken into consideration.