Opioid switching and variability in response in pain cancer patients.

INTRODUCTION: Opioid switching is a possible strategy for inadequate analgesia or unmanageable side effects. Its effectiveness ranges from 50 to 90% and is still debated. PURPOSE: We analyzed the impact of opioid switching in a cancer pain population treated with strong opioids for pain. METHODS: This is a post hoc analysis from a multicenter, randomized, four-arm, controlled, phase IV clinical trial. Outcome variables included the percentages of switches, the reasons for the switch, the dose changes before and after the switch, depending on the starting opioid, the response in case of inadequate analgesia, and unmanageable toxicity, and the variability of response among and within patients. RESULTS: We analyzed 498 patients. The opioid was switched in 79 patients (15.9%) 87 times, mainly for uncontrolled pain (52.3%), adverse opioid reactions (22.1%), both of these (4.8%), and dysphagia (20.8%). The reasons for switching varied depending on the starting opioid. Pain reduction was good after 51.45% of switches and control of opioid side effects was good after 43.5%. The relief of opioid-induced toxicity varied among adverse events and within each patient. The daily doses were higher after switching oral opioids and lower after transdermal drugs. CONCLUSIONS: Half of the patients who underwent switching experienced improved relief of pain or amelioration of opioid toxicity. The switch can help in the management of some cases but with many limits and uncertainties.

The Italian validation of the Anosognosia Questionnaire for Dementia in Alzheimer's disease.

Although the Anosognosia Questionnaire-Dementia (AQ-D) is one of the main instruments for assessing awareness in Alzheimer's disease (AD), the normative data were until now limited to people from Argentina and Japan. This study aims to validate this instrument in an European context, in particular in an Italian sample. In a multicenter project (Verona, Padova, and Trapani), 130 patients with AD and their caregivers participated in the study. Psychometric characteristics of AQ-D are confirmed indicating that the scale permits the early identification of anosognosia and the correct care management of patients. Indeed, anosognosia results to be present also in patients with very mild AD (moderate: 44.44%; mild: 47.17%; and very mild: 23.73%). Moreover, the results indicate that deficits in awareness may vary in severity and that different types of anosognosia may be identified.

Risk of mortality from cardiovascular and respiratory causes in patients with chronic obstructive pulmonary disease submitted to follow-up after lung resection for non-small cell lung cancer.

AIM: Considerable controversy surrounds mortality from non-neoplastic diseases during the postoperative follow-up of patients with non-small cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD). This study investigated the incidence of mortality from cardiovascular and respiratory (CVR) causes in patients with COPD submitted to follow-up after lung resection for NSCLC, and identified preoperative and postoperative risk factors. METHODS: A total of 398 patients with mild or moderate COPD were followed up in our department after lung resection for NSCLC (median follow-up 61 months). Statistical analysis of the data was carried out to determine the incidence and the prognostic factors of postoperative death from CVR causes. RESULTS: Of the 398 resected patients, 186 survived without tumor recurrence; 24/186 (12.9%) died of CVR causes (acute respiratory failure, pneumonia, pulmonary embolism, acute pulmonary edema, acute myocardial ischemia or stroke). These 24 patients had a higher frequency of pre-existing coronary artery disease or heart failure (P=0.0003), predicted postoperative FEV1 <1000 mL (P=0.0008), exertional dyspnea (P=0.0000), and 30-day operative cardiopulmonary complications (P=0.001). Protective features were young age (<40 years), early stage disease, and minor resection (lobectomy). Independently significant adverse prognostic factors were stage III-IV disease (cumulative CVR death rate 47% at 5-10 years; P=0.028 vs. stage I-II) and completion pneumonectomy or partial resection of the other lung for a second primary tumor (cumulative CVR death rate 50% and 57%, respectively, at 5-10 years; P=0.0016 vs. all other resections). Older age and tumor histology were significant risk factors only in patients with advanced stage disease. CONCLUSION: The findings suggest that postoperative CVR death may be expected in patients with COPD and advanced stage NSCLC or in those undergoing completion pneumonectomy or partial resection of the other lung for a second primary tumor. Other risk factors are previous coronary artery disease and/or heart failure, exertional dyspnea and predicted postoperative FEV1 <1000 mL.

[One case of cholangiocarcinoma in hepatic hilium only connected to increase GGT]. / Un caso di colangiocarcinoma dell'ilo epatico associato solo ad aumento della GGT.

This is the case of a patient 53 years old afflicted with cholangiocarcinoma infiltrated in the hepatic parenchyma and in soft tissues the of hepatic hilum. The patient was asymptomatic and objective examination was negative. The diagnostic suspicion was caused by the progressive increase of GGT, while the other indexes of hepatic functionality were normal. The diagnosis was confirmed by hepatic ultrasonography, abdominal TAC and, at last, by ERCP. The patient was operated by resection of bilious organs and multiple biliary-digestive anastomosis. Now he is in good health.

Castleman's disease. A case of angiofollicular lymphoid hyperplasia followed from diagnosis (1985) until 1995.

A case report is presented of a patient, (R.C.), who suffered from Castleman's syndrome or angiofollicular lymphoid hyperplasia. The first signs of the disease occurred in 1985 in the form of a left axillary adenopathy. The diagnosis was made after a surgical exeresis of the affected lymph nodes through an histologic test which revealed that it was a case of the plasmocyte version of Castleman syndrome. The histochemical tests showed the monoclonal nature (lambda chains) of the plasmocyte population. Since then the patient, who has been followed every six months with blood chemistries and instrumental check-ups, has not suffered any further relapses.

No effect of endurance exercise on serum bilirubin in healthy athletes and with congenital hyperbilirubinemia (Gilbert's syndrome).

Twenty male athletes, mean age 26 years, were studied by a work load test with cycle-ergometer, with increasing power output for 60 minutes until an intensity corresponding to 70% of the individual maximal heart rate was achieved. Ten of them had familial hyperbilirubinemia (Gilbert's syndrome) and ten had been considered as healthy controls. The diagnosis of Gilbert's syndrome was made using the following criteria: unconjugated hyperbilirubinemia, no systemic symptoms, no overt or clinically recognizable haemolysis, normal liver function tests. Blood levels of free fatty acids (FFA) showed a progressive significant increase after muscular exercise in both healthy and Gilbert's syndrome subjects (p < 0.001). The increase was more evident in controls compared to Gilbert's syndrome subjects (p < 0.05). Total and fractionated bilirubin showed no change in both groups. In conclusion, a competitive mechanism between bilirubin and FFA is probably responsible for the lower increase in plasma FFA in Gilbert's syndrome.