Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey.

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

[Staphylococcus nasal carriage and infection of central venous ports in oncology]. / Portage nasal staphylococcique et infection des systèmes d'accès veineux central en cancérologie.

OBJECTIVE: To assess the risk of infection of either subcutaneously implanted central venous access devices or percutaneous central venous catheters inserted via a subcutaneous tunnel in cancer patients with a positive staphylococcal nasal carriage. STUDY DESIGN: Prospective study. PATIENTS: The study included 266 patients undergoing cancer chemotherapy. METHOD: A nasal swab was taken prior to insertion of the venous access device and the patients were followed over 30 days for the occurrence of a staphylococcal infection (hemoculture and device or site of insertion). RESULTS: A nasal staphylococcal nasal carriage was found in 227 patients. Out of the 15 developing a device infection, a staphylococcal nasal colonization was existing in nine patients. Bacteriological screening a sensitivity of 60% and a specificity of 13%. CONCLUSION: Bacteriological screening at the time of device insertion of a central venous access device is of no value for the detection of patients at risk of staphylococcal infection of the device.

[Factor VII deficiency and surgery]. / Déficit en facteur VII et chirurgie.

Factor VII deficiency is a rare disorder (1/500,000), with manifestations similar to those experienced by patients with haemophilia. Excessive bleeding during surgical procedure is prevented by factor VII administration. We report two cases of patients presenting a factor VII deficiency who were treated for oncological surgery. In the first patient with a severe congenital factor VII deficiency (8%), a continuous infusion of factor VII prevented the development of perioperative bleeding. In the second case, with a probably acquired factor VII deficiency (33%) related to a leiomyosarcoma, bleeding was prevented by a single preoperative factor VII injection.

[Morphine therapy: evaluation of patient information]. / Thérapeutique morphinique: évaluation de l'information des patients.

Pain is frequent in the course of cancer and can have negative consequences on patients quality of life. The great majority of patients can be helped by simple treatments. The prescription of morphine (M) must be preceded by some explanations. In order to verify the reality of these explanations, a study was done in a 230 comprehensive beds Cancer Centre, with 129 patients, randomized between all the patients hospitalized. In an open questionnaire, different aspects were studied. One hundred answers were studied: 63 patients did not have M at any time: group M-; 37 patients had M (19) or have had M (18): group M+; 97% of the patients in group M+ thought that M decreased pain, for 85% patients in group M-. Morphine treatment was effective in 92% of patients M+, and not very effective in 5%; 67% of patients M- thought that M is efficient but 17% did not know; 76% of patients M+ did not worry about M; 13% worried et 11% did not know. For patients M- only 48% did not worry; 41% worried and 11% did not know. The side effect known by the patients, and spontaneously quoted were constipation (12 patients in M+ group). For 14 patients there was no problem and 2 did not know. In M- group 49 patients did not know. Only 8% of M+ group were afraid by addiction, but 44% in group M-; 97% patients M+ said that they could stop without problem against only 38% of the patients in M- group. For 16% of M+ group, the use of M had a bad signification about their disease, but 52% of M- group thought that if morphine was used in their cases, the meaning would be very bad. The differences between the two groups allow to think that the prescription of M in this study is explained, and that the patients receiving M are rather well informed. Patients with cancer but without M do not have good information and their knowledge is similar than general population. The use of recommended therapy and explanations allowed patients with M therapy to be comfortable with this prescription.

Energy expenditure during allogeneic and autologous bone marrow transplantation.

Resting energy expenditure (REE) was measured by indirect calorimetry during allogeneic and autologous bone marrow transplantation in order to evaluate the evolution in allogeneic and autologous recipient patients. REE values obtained with indirect calorimetry and compared with values using the Harris-Benedict formula were different. Evolution of REE during aplasia were significantly different in autologous and allogeneic recipients with an increase 11.5 ' 10.8 cent for autologous and a decrease of - 7.3 ' 8.9 cent in allogeneic bone marrow transplantation (BMT) patients. There were no differences in nutritional status and REE before BMT, at discharge and 1 month after discharge between the two groups but all patients had inflicted damage on their nutritional status at discharge from hospital after BMT. However, these patients differed because of the decrease in oral nutritional intake and an increase in the length of aplasia and hospital stay in allogeneic patients. Currently, there is no proof that recommendations for nutritional interventions or results of nutritional investigations in allogeneic BMT can be extrapolated in autologous patients. Harris-Benedict formula does not estimate the energy expenditure of patients submitted to massive chemotherapy and BMT with enough precision because of the great differences in individuals.

[Peripheral venous catheter embolism]. / Embolie de cathéter veineux périphérique.

The accidental embolization of peripheral venous catheter fragments seems to be a rare event. Removal of the catheter embolus is usually recommended, because of the high morbidity and mortality rates from sepsis, perforation, thrombosis and arrhythmias. We report a case, in which the diagnosis was made 17 years after the embolization by the means of a systematic chest X-ray. The use of spiral CT scan with computerized post-processing 3D reconstruction confirmed the diagnosis. Because of good tolerance during this very long term, a not-to-treat decision was taken.

Amphotericin B intralipid formulation: stability and particle size.

Amphotericin B remains the drug of choice for treating systemic fungal infections, although toxicity limits its clinical use. Some studies reported the use of Intralipid deoxycholate amphotericin B as an alternative delivery system. An in-vitro study was performed to assess the compatibility of deoxycholate amphotericin B in Intralipid. With two types of dilution of deoxycholate amphotericin B (in 5% dextrose and Intralipid or in Intralipid alone) the solution stability was not constant with a clear yellow precipitate. We observed an increase in the size of the particles (1.5-4-fold). In light of these results Intralipid deoxycholate amphotericin B should not be routinely administered.

Postoperative infections in immunocompromised patients after oncological surgery.

Immunodeficiency secondary to cancer chemotherapy (chemotherapy for less than 3 months, or intensive chemotherapy with bone marrow transplant) may be responsible for postoperative infections. To estimate the value of this hypothesis, a prospective study was done over a period of 18 months in patients who had undergone pulmonary surgery. Antibiotic prophylaxis was by pefloxacin, one tablet (400 mg) 1 h before surgery then 11 h after. Clinical examination, a chest X-ray and blood cell count were carried out every day for 10 days and on the 15th day. All the drain-tips were cultured. In a case of infection, samples were obtained and cultured. One group comprised 22 immunodeficient patients (group A), and 33 patients (group B) had received no prior chemotherapy (bone-marrow transplantation = 36.7%). There were differences between the two groups in age (A:33.5 +/- 12.3 years; B:50.8 +/- 18.4 years), and type of tumour (A: metastasis = 95.5%; B: lung cancer = 51.5%). Surgical operation was bilateral for 36.4% of the patients in group A. There was more anatomical resection (pneumonectomy and lobectomy) in group B. Lung function did not differ between the two groups (abnormalities: A = 54.6%; B = 63.6%). In group A, there were 3 pulmonary infections (13.7%), but in group B 10 infections (30.3%) with 9 pulmonary infections (4 with bacteraemia) and 1 wound infection. The bacteriological finding showed two pathogens in 7 cases and no bacteriological isolates in 2 cases. With broad-spectrum antibiotherapy all the patients were cured except 1. There was one postoperative death in group B. This patient died of respiratory distress after pneumonectomy complicated by pneumonia and septicaemia (Streptococcus pneumoniae) in the remaining lung. Surgical procedures are performed with increasing frequency on patients with immunocompromised status. Classically the risk of infection is more important for these patients. In this study prior cancer chemotherapy or bone marrow transplantation did not seem to be an aggravating factor of the risk of infection. But further methodological analysis would not allow us to distinguish between a real impact of chemotherapy and the influence of group heterogeneity.

Clinical evaluation of the CORDIS vascular access port systems: a multicenter study.

Two non-metallic vascular access port systems, the Multipurpose Access Port (MPAP) and Miniport, developed by CORDIS S.A., France, have been evaluated clinically in 78 cancer patients. During the investigational period covering a total experience of 369 treatment cycles and 1,370 infusion days, no cases of infection or septicemia were observed. Serious complications such as drug extravasation and catheter occlusion occurred, although the incidence was relatively low (+/- 1%) when compared with the number of treatment courses (cycles), but in relation to the number of patients included in this study, the procedure-related complication rate was 17.5% for the MPAP and 15.8% for the Miniport. Procedure-related complications can be avoided by proper handling and use of suitable drug combinations to minimize crystallization reactions within the port-catheter systems. The final complication rate (total minus procedure-related) in terms of termination of treatment, i.e. explantation of the port-catheter system was 12.1% for the MPAP and 12.5% for the MINIPORT, which generally confirms the results of other groups. More than 87% of both port-catheter systems were still functional at the end of evaluation.

A comparative study of controlled-release morphine (CRM) suspension and CRM tablets in chronic cancer pain.

This study compared the efficacy and the adverse effects of controlled-release morphine (CRM) suspension (SAR 213) and CRM tablets (Moscontin) in the treatment of cancer pain. This multicenter, randomized, double-blind, double-dummy, crossover study was carried out on 52 patients. Each patient received both study treatments given at an equivalent dosage of morphine during each of two 7-day periods. The primary outcome variable was the severity of pain assessed three times daily by means of a visual analogue scale. Secondary criteria of efficacy were the severity of pain assessed by verbal rating scale, the need for "rescue" doses of immediate-release morphine, treatment preference, and indices of quality of life (activity, mood, sleep). There were no statistically significant differences in the parameters assessed when comparing the two groups. This study shows that, when prescribed at the same doses, CRM suspension and CRM tablets have similar efficacy and adverse effects, as well as the same duration of action. The results of this first clinical study carried out on CRM suspension are especially relevant for patients with cancer pain who have difficulty swallowing.

Phase I trial of recombinant interleukin-2 followed by recombinant tumor necrosis factor in patients with metastatic cancer.

In this Phase I trial, the feasibility of sequential administration of continuous intravenous recombinant interleukin-2 (rIL-2) at 18 x 10(6) IU/m2/day for 6 days, followed by three daily bolus intravenous recombinant tumor necrosis factor (rTNF) infusions at doses escalating between 10 and 120 micrograms/m2/day, was investigated in 31 patients with metastatic malignancies. Prophylactic use of indomethacin prior to and during rTNF administration was found to significantly reduce toxicity. However, despite prophylactic indomethacin, a maximum tolerated dose of rTNF of 120 micrograms/m2 was reached. The limiting toxicity was hypotension. Predictable flu-like toxicities (i.e., fever/chills, hypotension, gastrointestinal toxicity, edema, malaise) were seen in most patients. These started during the rIL-2 infusion and continued during rTNF administration, particularly in the absence of indomethacin. Hematological, renal, and hepatic toxicities were not dose limiting. These toxicities were all reversible after treatment interruption. Pulmonary toxicity [i.e., anaphylactic-like reactions, bronchospasms, and adult respiratory distress syndrome (ARDS)] was seen in several patients immediately after rTNF infusions, irrespective of the rTNF dose or treatment cycle, and mainly in patients with extensive pulmonary metastases. The combined effect of treatment-related ARDS, lung metastases, and a Guillain-Barré syndrome led to the death of one patient. Two partial responses were seen in this study (i.e., breast and renal cancer). Based on these results, a Phase II trial of rIL-2 followed by rTNF has been initiated in metastatic breast cancer patients.

[Perforation of the esophagus during attempted endotracheal intubation]. / Perforation de l'oesophage par fausse route lors de l'intubation trachéale.

A case is reported of oesophageal perforation which occurred during an attempt to carry out endotracheal intubation. A 54-year-old female patient was scheduled for mastectomy. She had no clinical features likely to predict a difficult endotracheal intubation. After induction with thiopentone, phenoperidine and suxamethonium, three attempts were made to carry out tracheal intubation with a Mallinckrodt Lo-pro tube, internal diameter 7.5 mm. During the third attempt, the oesophagus was accidentally intubated. The diagnosis was made before any insufflation was carried out. Another anaesthetist took over, and intubated the patient. At that time, there was left-sided cervical emphysema which quickly spread. An oesophageal perforation was suspected, and the patient was given 500 mg of metronidazole and 1 g of cefotetan. Postoperatively, the antibiotics were continued, and the patient had nothing by mouth. Oesophagography showed a posterior fistula in the upper third. Conservative treatment was continued until the seventh day, when another oesophagography was carried out. This showed that the perforation had completely healed. This rather rare complication of endotracheal intubation may have a poor prognosis if it results in mediastinitis. The diagnosis and prognosis of this complication and its treatment, whether conservative or surgical, are discussed.

[Electromagnetic location of central venous catheters]. / Repérage électromagnétique des cathéters veineux centraux.

A new technique, the Cath Finder (Pharmacia Deltec) system, for locating central venous catheters is described. It was initially designed to facilitate the insertion of the PAS Port (Pharmacia Deltec), a long central venous catheter with an implantable chamber. It is based on a low intensity high frequency electromagnetic field generated by a locator wand. A preconnected sensor guide wire is introduced into the catheter so as to make the catheter tip detectable by the electromagnetic field. The wand is placed over an appropriate landmark on the anterior chest wall (third right rib, parasternally). When the centre of the field has been passed over by the sensor tip in the catheter-sensor assembly, a light signal is set off. This technique is simple and easily mastered. It is far less cumbersome than the usual techniques, like fluoroscopy and chest X-rays. The Cath Finder provides reliable continuous information on the position of the catheter tip during its insertion. It seems to provide an acceptable alternative to peroperative fluoroscopy. The accuracy of this system was assessed in ten patients. All had malignancies and required long term central venous access. In 6 cases, catheterisation and locating of the catheter were uneventful. In 2 cases, the catheter entered a wrong vein. The diagnosis having been made with the Cath Finder system, the false route was amended and the catheter placed accurately. In one case, the sensor in the catheter broke.(ABSTRACT TRUNCATED AT 250 WORDS)

[Adverse effects of interleukin 2]. / Effets secondaires de l'interleukine 2.

Interleukin 2, has frequent and important side effects. Toxic effects observed are systemic (fever, chills, malaise), hemodynamic (capillary leak syndrome, hypotension), cardiac (arrhythmia, infarction), renal (renal dysfunction), infectious (septicemia), cutaneous, hematologic, gastrointestinal, endocrinologic and metabolic. Side effects are dose-dependent, generally reversible, with a mortality from 1 to 3%. Regimens of administration and other cytokine combinations affect interleukin 2 toxicity. If the treatment of these side effects is well known, selection of patients and specialized care unit remain always necessary.