Hydromorphone for dyspnoea in terminally ill patients with cancer: case series.

OBJECTIVE: Opioids can mitigate dyspnoea, but the efficacy of hydromorphone use for dyspnoea in patients with cancer is not well known. METHODS: Patients with cancers with more than mild dyspnoea treated with subcutaneous injection of hydromorphone between March 2020 and February 2022 at Kitano Hospital (Osaka, Japan) were reviewed retrospectively. Only patients who could self-report their symptoms ≥3 days after the start of hydromorphone therapy were included. Dyspnoea severity was rated on a five-point scale (0: 'not bothersome'; 1: 'mild'; 2: 'moderate'; 3: 'severe'; 4: 'overwhelming'). RESULTS: Fifteen patients (2 with moderate, 12 with severe and 1 with overwhelming dyspnoea) were deemed eligible. The median interval from the start of hydromorphone initiation to death was 19 (IQR, 11-37) days. Thoracic drainage and palliative sedation after the start of hydromorphone therapy was undertaken in three and two patients, respectively. At 3 days, the median score of the Dyspnoea Rating Scale was improved significantly from 3 to 2 compared with that at baseline (p=0.0023). The intensity of dyspnoea was improved in 11 patients (73%). Opioid-related adverse events were not observed within 3 days. CONCLUSIONS: Using hydromorphone for dyspnoea in patients with cancer seems to be appropriate if morphine use is contraindicated.

Fentanyl titration for cancer pain: continuous subcutaneous injection and a once-daily transdermal patch - case series.

OBJECTIVES: Continuous subcutaneous injection (CSCI) followed by a once-daily transdermal patch is a reasonable strategy for rapid titration of fentanyl in patients with cancer pain who are unable to take oral medication or have renal impairment, but the effectiveness and safety have not been demonstrated. METHODS: Medical records of patients with moderate to severe cancer pain who underwent titration of fentanyl by CSCI between October 2019 and October 2021 at Kitano Hospital, Osaka, Japan, were retrospectively reviewed. The dose of fentanyl was increased to a maximum of 0.05 mg/hour. If the dose was inadequate, the fentanyl patch was added on CSCI. When pain relief was adequate, CSCI was completely converted to the patch. RESULTS: Thirty-three patients were enrolled. Titration was completed successfully in 28 patients (85%) over a median of 2 days. The average Numeric Rating Scale for pain decreased by at least 66% in 22 patients (67%) and by at least 33% in 7 (21%). After conversion to the patch, two patients (6.1%) required to increase the dose of fentanyl within a week. Two patients (6.1%) experienced moderate drowsiness during titration. CONCLUSIONS: Fentanyl titration by CSCI is an effective and safe method for achieving rapid pain control.

[Predicting the Prognosis of Terminal Cancer Patients with Chemotherapy].

To determine the chemotherapy indication of terminal cancer patients, predicting the prognosis is meaningful. We intended to establish a suitable prognosis prediction index for these patients. From June 2015 to January 2016, we examined the prognosis in 7 patients who were administered chemotherapy drugs within 4 weeks before or after the prognosis calculation. Palliative prognostic index(PPI)was calculated prospectively, and prognosis in palliative care study(PiPS)was calculated prospectively or retrospectively. If patients had laboratory data within 4 days before prognosis calculation, they were assessed with PiPS-B. If patients did not have recent data, they were assessed with PiPS-A. The absolute agreement of prognosis index with actual survival was 100% in PPI, and 40.0% in PiPS. All patients who were administered chemotherapy after the PPI calculation were considered to have survived for more than 42 days. We concluded that PPI was a suitable prognosis prediction index for terminal cancer patients with chemotherapy. PPI was useful for determining the chemotherapy indication in these patients.

Colonoscopic classification of internal hemorrhoids: usefulness in endoscopic band ligation.

BACKGROUND: Bleeding is one of the main symptoms of internal hemorrhoids. However, the conventional Goligher's classification of internal hemorrhoids does not consider the severity of bleeding. We intended to establish a useful method for evaluating internal hemorrhoids using a colonoscope that reflected the severity of the symptoms. METHODS: Using a colonoscope in the retroflexed and forward viewing position, 104 patients with symptomatic internal hemorrhoids were evaluated based on the criteria of range, form and red color signs (RCS). Range was determined by the circumferential distribution of internal hemorrhoids and scaled from 0 to 4. Form was determined by size and scaled from 0 to 2. The presence of RCS was also evaluated. Symptoms were determined by interview and scaled from 0 to 3. Patients were treated by endoscopic band ligation (EBL) and were examined endoscopically before and 4 weeks after the treatment. RESULTS: Before the treatment, range, form and RCS were significantly correlated to bleeding (P < 0.01), and form was significantly correlated to prolapse (P < 0.05). The endoscopic classification scores at 4 weeks after EBL improved significantly (range from 3.25 +/- 0.05-0.56 +/- 0.08 [P < 0.01] and form from 2.81 +/- 0.04-0.56 +/- 0.07 P < 0.01). CONCLUSION: The new endoscopic classification of internal hemorrhoids proved to be closely correlated to symptoms, particularly bleeding, and thus highly useful in evaluating the effectiveness of the treatment.

Retroflexed endoscopic multiple band ligation of symptomatic internal hemorrhoids.

BACKGROUND: Elastic band ligation is a well-established nonoperative method for treatment of internal hemorrhoids that give rise to symptoms. This study assessed the efficacy and safety of retroflexed endoscopic multiple band ligation, a procedure that involves extensive ligation of internal hemorrhoids, and the immediately proximal normal rectal mucosa, by means of a retroflexed endoscope. METHODS: Eighty-two patients with symptoms caused by internal hemorrhoids (15, stage I; 19, stage II; 47, stage III; 1, stage IV) were treated by retroflexed endoscopic multiple band ligation. Symptoms (prolapse, bleeding, pain with defecation) were graded from 0 to 3. Range and form of the internal hemorrhoids were evaluated endoscopically. Retroflexed endoscopic multiple band ligation was performed by using a flexible endoscope with an attached band ligation device in the retroflexed position. RESULTS: A mean of 8 bands (range 4-14) were placed per treatment session. Seventy-six patients were treated in a single session, 5 in two sessions, and one in 3 sessions. Symptom and endoscopic scores improved at 4 weeks after the retroflexed endoscopic multiple band ligation: bleeding, from 1.26 to 0.53 (p<0.01); prolapse, from 1.94 to 0.5 (p<0.01); pain, from 1.03 to 0.93 (p=0.67); Goligher classification, from 2.41 to 1.09 (p<0.01); range, from 3.25 to 0.56 (p<0.01); and form, from 2.81 to 0.56 (p<0.01). Long-term response (mean follow-up 12 months, range 3-40 months) was excellent for 89% of the patients, good for 9%, and poor for 2%. No major complication was noted. CONCLUSIONS: Retroflexed endoscopic multiple band ligation is a safe and effective method for treatment for patients with symptoms caused by internal hemorrhoids.

Cyclooxygenase-2 expression and angiogenesis in gastric hyperplastic polyp--association with polyp size.

BACKGROUND: Cyclooxygenase (COX)-2 is the rate-limiting enzyme in prostaglandin synthesis, and plays an important role in tumor enlargement. COX-2 is expressed in human gastric and colorectal tumors, and the expression increases in a tumor size-dependent manner. In the present study, we attempted to examine the COX-2 expression pattern in gastric hyperplastic polyp, a non-tumorous lesion. PATIENTS AND METHODS: Fifty-eight gastric hyperplastic polyps, obtained by endoscopic polypectomy, were immunostained with anti-COX-2 and antivascular endothelial growth factor (VEGF) antibodies. Microvessel density (MVD) was determined by von Willebrand factor immunostaining. RESULTS: In larger gastric hyperplastic polyps, COX-2 was expressed mainly on the luminal side of the polyp stroma, while it was absent in smaller polyps. A significant correlation between COX-2 immunoreactivity and polyp size was observed (p < 0.01). High VEGF expression and MVD were observed mainly in the same stromal region of the polyps where COX-2 was expressed. Both VEGF expression and MVD were also correlated with polyp size significantly (ps < 0.01). CONCLUSIONS: COX-2 expression increased in a size-dependent manner in non-tumorous hyperplastic polyps, suggesting that COX-2 expression is not necessarily linked to epithelial cell transformation. Moreover, COX-2 may participate in polyp enlargement through angiogenesis by promoting VEGF production.