Rapid-onset opioids for the treatment of breakthrough cancer pain: two cases of drug abuse.

SETTING: In the last few years, the use of opioids for cancer pain has rapidly increased and new molecules have been developed. Currently, rapid-onset opioids are widely used in clinical practice for breakthrough cancer pain (BTcP). However, the tolerability of these molecules is still a matter of debate. PATIENTS: We describe two cases of rapid-onset opioids misuse that have been recently observed at our palliative care unit. DISCUSSION: The reported cases are explicative as they occurred in patients suffering from different types of cancer and with different causes of BTcP. Further investigations are needed to identify factors predicting addiction to this new class of molecules.

[Voluntary mediation in healthcare disputes: the experience of the "Fondazione IRCCS Istituto Nazionale dei Tumori" in Milan (Italy)]. / La mediazione volontaria nelle controversie in sanità: l'esperienza della Fondazione IRCCS Istituto Nazionale dei Tumori - Milano.

The "Fondazione IRCCS Istituto Nazionale dei Tumori" ( National Tumour Institute) in Milan (Italy) offers mediation services aimed at restoring communication between patients and healthcare professionals, when their relationship has been altered by a conflict during the diagnosis or treatment process. A method derived from transformative mediation is used. The purpose of mediation is not to examine clinical aspects, nor to identify who is right and who is wrong. Individual sessions are often sufficient to reduce litigation.

Palliative care in a national cancer center: results in 1987 vs. 1993 vs. 2000.

In the last few years, palliative care for advanced and terminal cancer patients has undergone considerable evolution. We determined the characteristics of patients admitted to the 4-bed Palliative Care Unit (PCU) of the National Cancer Institute (NCI) of Milan in 1987, 1993 and 2000 to evaluate how our diagnostic and therapeutic approaches have changed over the years. We reviewed the charts of every patient admitted to the PCU in 1987, 1993, and the first ten months of 2000. We recorded demographic data; the primary tumor sites; the main reason for admission; the types of therapies administered (oncologic, analgesic, surgical, neurosurgical analgesic procedures, and supportive therapy); the type and number of cardiological, radiological and endoscopic examinations, as well as specialist consultations; the duration of stay and eventual death on the Unit. There were no significant differences regarding gender, age, primary tumor site and death in hospital of the patients admitted during these years. The time spent in hospital increased over time (P = 0.006). A significant increase was observed in the percentage of patients admitted for supportive therapy (P < 0.001) and investigation concerning the stage of the disease (P < 0.001). There was a significant decrease in admission for invasive analgesic procedures (P < 0.001), as well as for pain diagnosis and/or uncontrolled pain. Uncontrolled pain remained the most frequent reason for admission. Over the years, during hospitalization, 7% to 12% of the patients underwent radiotherapy,1% to 9% had computerized tomography, and 4% to 8% had palliative surgery. More than 50% of the patients received intravenous hydration; a few patients received hypodermoclysis in 1987. Over time, there was a significant increase in "as needed" administration of nonsteroidal anti-inflammatory drugs and a significant reduction in their regular administration (from 24% in 1987 and 1993 to 3% in 2000) (P < 0.001). The use of codeine, tramadol and methadone increased (P < 0.001), whereas the use of oral morphine, buprenorphine and oxycodone decreased in 2000 (P < 0.001). There was a reduction in the use of antidepressants (no significant constant trend) and a significant increase in the use of anticonvulsants, laxatives and pamidronate (P < 0.001). Regularly administered hypnotics decreased in 1993 and increased in 2000 (P < 0.001). Over these years, no significant differences were found in the routes of opioid administration, in route switching and in the mean maximum oral opioid dose (ranging from 108 to 126 mg/day). The percentage of patients undergoing percutaneous cordotomy significantly decreased in 1993 and 2000 (P < 0.001). Over time, there was an increase in requests for specialist consultations, which was significant for neurological, cardiological and oncological consults (P < 0.001). Although the characteristics of the patients admitted to the PCU did not change over these years, there have been significant modifications in our therapeutic approaches, above all in the use of supportive therapy, adjuvant drugs, opioids and neurosurgical invasive procedures. Moreover, a major collaborative interaction with other specialists of the NCI took place with the aim to tailor treatment for each single patient.

Quality for home palliative care: an Italian metropolitan multicentre JCI-certified model.

BACKGROUND: Assessing the quality of care and service delivery through the analysis of ad hoc indicators is a relevant process for quality monitoring and improvement with a view to providing patients, the community and administrators alike with appropriate elements of evaluation. This paper describes the key results of a certification process based on the Joint Commission International (JCI) criteria for the home hospitalisation model implemented by the palliative care units of seven Milan hospitals for terminally ill patients with cancer. METHODS: In 2006, the interhospital working team implemented a certification project based on the JCI Disease or Condition-Specific Care (DSCS) programme. Thirty standards subdivided into five functional areas with 150 measurable elements were the starting-point for periodic improvement plans within and across participating hospitals. Programme compliance was analysed in terms of annual performance improvement and consistency across the seven PCUs involved in achieving set goals. The JCI standards were applied on 3316 terminally ill patients with cancer treated at home from 2005 to 2009. RESULTS: As a result of the work carried out, the JCI survey conducted 3 years after project implementation demonstrated full compliance with the established standards, leading to the JCI certification award (for the first time in this clinical setting internationally). CONCLUSION: The work carried out with a view to certification has confirmed the possibility that facilities spread across different hospitals can actually share common processes and standardise the activities for the care of end-of-life patients with cancer at home as if they were one single service provider.

Quality for home palliative care: an Italian metropolitan multicentre JCI-certified model.

BACKGROUND: Assessing the quality of care and service delivery through the analysis of ad hoc indicators is a relevant process for quality monitoring and improvement with a view to providing patients, the community and administrators alike with appropriate elements of evaluation. This paper describes the key results of a certification process based on the Joint Commission International (JCI) criteria for the home hospitalisation model implemented by the palliative care units of seven Milan hospitals for terminally ill patients with cancer. METHODS: In 2006, the interhospital working team implemented a certification project based on the JCI Disease or Condition-Specific Care (DSCS) programme. Thirty standards subdivided into five functional areas with 150 measurable elements were the starting-point for periodic improvement plans within and across participating hospitals. Programme compliance was analysed in terms of annual performance improvement and consistency across the seven PCUs involved in achieving set goals. The JCI standards were applied on 3316 terminally ill patients with cancer treated at home from 2005 to 2009. RESULTS: As a result of the work carried out, the JCI survey conducted 3 years after project implementation demonstrated full compliance with the established standards, leading to the JCI certification award (for the first time in this clinical setting internationally). CONCLUSION: The work carried out with a view to certification has confirmed the possibility that facilities spread across different hospitals can actually share common processes and standardise the activities for the care of end-of-life patients with cancer at home as if they were one single service provider.