Manejo de la hiperglucemia en el paciente con enfermedad oncológica avanzada (EOA) / Management of hyperglycaemia in patients with advanced cancer

Las alteraciones glucémicas ocurren frecuentemente en pacientes con enfermedad oncológica avanzada (EOA), incluso en los que nunca recibieron diagnóstico de diabetes, como consecuencia tanto de una diabetes preexistente como de tratamientos y/o condiciones clínicas que afectan la homeostasis glucídica. La gestión de la hiperglucemia en enfermos con EOA es compleja debido a la falta de acuerdo con respecto a la frecuencia de los controles, la intensidad del tratamiento, y los objetivos glucémicos. La ausencia de estudios prospectivos dificulta ulteriormente la formulación de recomendaciones basadas en la evidencia. Sin embargo, la actualidad y la relevancia del problema imponen un esfuerzo de revisión de los datos disponibles con el objetivo de facilitar la colaboración entre profesionales y mejorar la atención a los enfermos. Esta revisión hará hincapié en los datos más recientes sobre el manejo de la glucemia en pacientes con EOA y tratará de destacar los aspectos clínicos más relevantes que deberían dirigir las elecciones terapéuticas

Glycaemic disorders frequently occur in patients with advanced cancer, even in those who have never been diagnosed as having diabetes, due to treatments and/or clinical conditions that affect glycaemic homeostasis. Hyperglycaemia management in patients with advanced cancer is complex, due to the lack of consensus on frequency of controls, intensity of treatment and glycaemic targets. The absence of prospective studies further hampers evidence-based recommendations. However, the topicality of this important clinical issue merits a comprehensive revision of the available literature, aimed at improving communication between health professionals and, ultimately, ameliorating patient care. This review will focus on the most recent data on the management of blood glucose in patients with advanced cancer, and will try to highlight the most relevant clinical aspects which should guide treatment choices

Respuesta a la carta «La intensidad de la atención y el alivio de síntomas» / Response to the letter ‘Intensity of patient care and symptom relief’

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¿Qué referencias espirituales verbalizan los pacientes atendidos por un equipo hospitalario de cuidados paliativos? / Which spiritual sentences are expressed by patients attending a palliative care unit?

OBJETIVO: Registro de las expresiones con contenido espiritual del paciente a través de sus verbalizaciones espontáneas mientras es atendido por un equipo de cuidados paliativos. Material y MÉTODO: Estudio prospectivo de registro textual de comentarios con referencias espirituales que los pacientes verbalizaron y que posteriormente se clasificaron en los diferentes dominios y necesidades espirituales. Pacientes atendidos por el equipo de cuidados paliativos entre noviembre de 2009 y mayo de 2010. Se recogieron datos sociodemográficos y datos clínicos como: ubicación del paciente, contenido del comentario/s, fecha del comentario, profesional al que se le transmite, género, edad y localización tumoral. RESULTADOS: Durante el periodo de estudio el equipo de cuidados paliativos atendió a 276 pacientes nuevos de los cuales 86 (31,2%) verbalizaron 119 comentarios espirituales y 102 necesidades espirituales. La localización tumoral más frecuente fue la de neoplasia de pulmón (16,2%). La edad media de la muestra fue de 68,8 años siendo el 58% hombres. El personal de enfermería fueron las profesionales que más comentarios espirituales identificaron (41,2%) y la interconsulta hospitalaria la ubicación donde más se registraron (48,8%). Con relación a los dominios espirituales, el 67,4% de los 86 pacientes expresaron al menos una verbalización que se incluía en el dominio intrapersonal, el 51,2% expresaron al menos un comentario referente al dominio interpersonal y el 19,8% de los pacientes lo hicieron dentro del dominio transpersonal. Del dominio intrapersonal se destacaba que un 41,8% de los pacientes que expresaron comentarios espirituales se referían a la desesperanza-deseos de morir. Respecto a las necesidades espirituales, los porcentajes más elevados correspondieron a la necesidad de volver a leer su vida (un 22% de los pacientes) y a la necesidad de encontrar sentido a la existencia y el devenir: la búsqueda de sentido (un 25,5% de los pacientes). CONCLUSIONES: En un tercio de los pacientes atendidos se detectaron expresiones con referencia espiritual. El porcentaje de pacientes que expresaron comentarios espirituales podría haber sido mayor si se hubiera diseñado un plan específico de intervención para evaluar y abordar las cuestiones espirituales

AIM: To record spiritual expressions made spontaneously by patients while attending a palliative care unit. MATERIAL AND METHOD: Prospective study registering all sentences made spontaneously by PATIENTS: Sentences were subsequently classified into different domains and spiritual needs by the palliative care professionals. Patients seen by the palliative care team between November 2009 and May 2010. Socio-demographic and clinical data such as: location of the patient, the content of the comment/s, date of the comment, professional that is transmitted, gender, age and tumor location were collected. RESULTS: During the study period the palliative care team attended 276 new patients, of whom 86 (31.2%) expressed 119 comments spiritual and 102 spiritual needs. Nurses were the professionals who identified more spiritual comments (41.2%) and the hospital consultation the location where most were recorded (48.8%). In relation to the spiritual domains, 93.7% of the 86 patients expressed expressions that were included in the domain of intrapersonal, 61.7% made reference to the interpersonal domain and 26.8% to the transpersonal. Within the intrapersonal domain highlighted that a 41.8% of the patients with spiritual comments referred to hopelessness- desire for hastened death. Respect to the spiritual needs the highest percentages corresponded to the need to lifetime re-examination (22% of patients) and the need to look for meaning to existence (25.5% of patients). CONCLUSIONS: Almost one third of patients expressed spiritual features. The percentage of patients who expressed spiritual comments could have been greater if a specific plan of action to assess and address the spiritual issues had been designed

Have We Improved Pain Control in Cancer Patients? A Multicenter Study of Ambulatory and Hospitalized Cancer Patients.

BACKGROUND: Pain in cancer patients is recognized as a major health problem, yet few studies of both inpatient and outpatient populations have been carried out. OBJECTIVE: The study objective was to assess the frequency, type, and characteristics of pain in adult cancer patients, including both inpatients and outpatients. METHODS: This cross-sectional study involved 1064 adult cancer patients (437 outpatients and 627 inpatients) from 44 hospitals and/or long-term-care centers in Catalonia, Spain. Cancer patients suffering from pain of any etiology for ≥2 weeks and/or under analgesic treatment ≥2 weeks were enrolled. Demographic and pain data were collected. The Spanish version of the Brief Pain Inventory was used to assess pain. RESULTS: Pain frequency was 55.3%. Pain was less frequent in outpatients than inpatients (41.6% versus 64.7%; p<0.001), although median pain duration was longer in outpatients (20 versus 6 weeks; p<0.001). Pain was assessable in 333 patients, and intensity was similar in both out- and inpatients; however, outpatients reported less improvement, less pain interference with daily life, and less pain related to the cancer per se. In both groups, patients with multiple myeloma (73%), breast (65%), and lung cancer (61%) were most likely to report pain. CONCLUSIONS: Pain in cancer patients, both ambulatory and hospitalized, remains a challenge for health care professionals, health administrators, and stakeholders. Our study reveals the high level of pain and distress that cancer patients continue to suffer, a problem that is particularly notable in outpatients due to the intensity and duration of the pain.

Effectiveness of palliative care services in symptom control of patients with advanced terminal cancer: a spanish, multicenter, prospective, quasi-experimental, pre-post study.

CONTEXT: In implementing the National Strategy of Palliative Care in Spain, there needs to be an evaluation of services, especially of their effectiveness, efficiency, and satisfaction of patients and families. OBJECTIVES: To assess the effectiveness of palliative care services (PCS) in improving symptom control in Spain. METHODS: This multicenter, prospective, quasi-experimental, pre-post intervention study evaluated symptoms, such as pain, breakthrough pain, anorexia, nausea/vomiting, constipation, insomnia, dyspnea at rest and with movement, anxiety, and depression, using patient-reported numeric rating scales on Days 0, 7, and 14 after referral to a PCS. RESULTS: Of the 318 PCSs included in the National Directory for 2004, 105 services in the 17 autonomous regions of Spain were able to report 265 eligible (treatment-naïve) patients. Nonparticipation by some centers was because of excessive workload or because their patients were not treatment-naïve. Median survival was 42 days. Pain severity and number of crises of breakthrough pain significantly improved, as did other indicators of patient satisfaction. Symptom improvement was independent of type of service (in acute bed hospitals, medium-term stay facilities, hospital support teams, home care support teams, and outpatient clinics). CONCLUSION: Our national plan appears to be successful in reducing symptoms irrespective of the type of organization providing the PCS. An area for improvement could be to lessen the workload of individual teams.

Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome.

This study aimed to assess the efficacy and safety of megestrol acetate (MA) in anorexia-cachexia syndrome (ACS). Literature and relevant databases were searched for randomized controlled trials of MA to treat ACS in patients with cancer, AIDS, or other pathologies. Data were extracted by two independent reviewers, and meta-analyses were performed where possible. Twenty-six studies were included (n=3,887). Compared to placebo, MA increased appetite in oncology patients [RR=2.31 (95% CI 1.52-3.59)], led to weight gain [RR=1.88 (95% CI 1.43-2.47)] and improved HRQOL [RR=1.52 (95% CI 1.00-2.30)]. In AIDS patients, it increased weight [RR=2.16 (95% CI 1.45-3.21)]. MA showed significant benefits over dronabinol in improving appetite, but no statistically significant advantages over other drugs for treating ACS were observed. There were no appreciable differences between lower (<800 mg/day) and higher (>800 mg/day) doses of MA. Few serious adverse events were recorded. MA is an effective and safe treatment for ACS in cancer and AIDS patients, particularly in terms of improvement in appetite and weight gain.