Amanda Caruselli

Sleep Disturbances in Patients With Advanced Cancer in Different Palliative Care Settings.

CONTEXT Information regarding sleep disturbances in the population with advanced cancer is meager. OBJECTIVES To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care settings. METHODS This was an observational study performed in different settings of palliative care. A consecutive sample of patients with advanced cancer was prospectively assessed for a period of six months. Epidemiological and clinical data, treatments received in the last month, Karnofsky status, Edmonton Symptom Assessment System scores, and concomitant medical treatment were recorded. Patients were administered the Athens Insomnia Scale and the Hospital Anxiety and Depression Scale (HADS). RESULTS A total of 820 patients were surveyed. Mean age was 69.7 years (SD 12.7), and 429 patients were males. Consistent sleep disturbances (moderate to maximum) were found in 60.8% of patients. Aged patients were less likely to have sleep disturbances, whereas a poor Karnofsky level was significantly associated with sleep problems. Breast, gastrointestinal, head and neck, lung, and prostate cancers were associated with sleep problems. Patients who had a secondary school or undergraduate education had less sleep disturbances. Hormone therapy and use of opioids and corticosteroids were positively associated with sleep disturbances, and there was a positive correlation of HADS-Anxiety and HADS-Depression scores with sleep disturbances. CONCLUSION More than 60% of palliative care patients have relevant sleep disturbances. Several factors associated with sleep disorders have been identified and should prompt physicians to make a careful examination and subsequent treatment of these disturbances.

The Palliative-Supportive Care Unit in a Comprehensive Cancer Center as Crossroad for Patients' Oncological Pathway.

Aim The aim of this study was to assess how an admission to an acute palliative-supportive care unit (APSCU), may influence the therapeutic trajectory of advanced cancer patients. Methods A consecutive sample of advanced cancer patients admitted to APCU was assessed. The following parameters were collected: patients demographics, including age, gender, primary diagnosis, marital status, and educational level, performance status and reasons for and kind of admission, data about care-givers, recent anticancer treatments, being on/off treatment or uncertain, the previous care setting, who proposed the admission to APSCU. Physical and psychological symptoms were evaluated at admission and at time of discharge. The use of opioids was also recorded. Hospital staying was also recorded. At time of discharge the parameters were recorded and a follow-up was performed one month after discharge. Results 314 consecutive patients admitted to the APSCU were surveyed. Pain was the most frequent reason for admission. Changes of ESAS were highly significant, as well as the use of opioids and breakthrough pain medications (p <0.0005). A significant decrease of the number of “on therapy” patients was reported, and concomitantly a significant number of “off-therapy” patients increased. At one month follow-up, 38.9% patients were at home, 19.7% patients were receiving palliative home care, and 1.6% patients were in hospice. 68.5% of patients were still living. Conclusion Data of this study suggest that the APSCU may have a relevant role for managing the therapeutic trajectory of advanced cancer patients, limiting the risk of futile and aggressive treatment while providing an appropriate care setting.

Pain Intensity as Prognostic Factor in Cancer Pain Management

The aim of this study was to prospectively assess the prognostic value of initial pain intensity and its duration in advanced cancer patients.

Frequency and Indications of Parenteral Nutrition in an Acute Palliative Care Unit.

The aim of this study was to estimate the use of parenteral nutrition (PN) in advanced cancer patients enrolled in an acute pain relief and palliative care unit of a comprehensive cancer center and the appropriateness of the criteria to select patients for PN. Fourteen out of 750 patients (1.8%) admitted to an acute palliative care unit were administered PN. Patients were referred from various settings. The mean age was 58 yr (range 37–79), and 9 were males. The mean hospital stay was 7.7 days (range 3–14), and the mean Karnofsky level was 35 (range 10–50). The principal indication was bowel obstruction. Ten patients (71%) were already receiving PN before admission, and 2 of them discontinued the treatment during admission. Four patients (29%) started PN during hospital admission as decided by the staff. Twelve patients (85%) were discharged on PN. One week after hospital discharge, 9 patients were still receiving PN, 4 patients died, and no data were available for 1 patient. One month after hospital discharge only 2 patients of these were still on PN, 2 patients discontinued PN, and 5 patients died. This study shows that decisions to start or to stop PN were individually based on multiple considerations, not only clinical. Goals may vary from expected clinical benefits to compassionate use. The administration of PN should be assessed carefully and individually approached.

Background and episodic breathlessness in advanced cancer patients followed at home

Abstract Background: The aim of this study was to assess the phenomenon of episodic breathlessness in advanced cancer patients followed by palliative care services at home. Methods: A consecutive sample of patients with advanced cancer, admitted to home care for a period of six months, was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity, and drugs used for their treatment were collected. Factors inducing episodic breathlessness, and its influence on daily activities were investigated. Results: Three hundred forty-seven advanced cancer patients admitted to home palliative care were surveyed. The prevalence of breathlessness was 35.3%. The mean intensity of breathlessness was 3.8 (SD 1.96), out of a maximum score of 10 for worst imaginable. Sixty patients (49.2%) were receiving drugs for background breathlessness. In the multivariate analysis the risk of breathlessness increased with cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer while it decreased in patients with a better performance status. The prevalence of episodic breathlessness in patients with background breathlessness was 79.5% and its mean intensity was 7.1 (SD 1.5, range 2–10). The mean duration of episodic breathlessness was 28.6 minutes (SD 47.1, range 1–300 minutes). Forty-three patients (44.3%) were receiving one or more drugs as needed. The majority of episodic breathlessness events were triggered by activity. Episodic breathlessness was interfering with daily activities in 65 patients (67%). Episodic breathlessness wasn’t associated with any variable taken into consideration. Conclusion: This study showed that episodic breathlessness frequently occurs in advanced cancer patients admitted to home care, is severe in intensity, is triggered in most cases by activity, and is characterized by a short duration which requires rapid measures.

The use of ketamine in a palliative-supportive care unit: a retrospective analysis

BACKGROUND To assess the response to ketamine in patients with difficult pain syndromes. METHODS The charts of patients with uncontrolled pain despite opioid dose escalation of at least two opioids or a combination of them, selected for a burst of ketamine and midazolam were reviewed. One hundred mg/day of ketamine and midazolam 15 mg/day by a continuous intravenous infusion for about 48 hours was offered to patients. RESULTS Forty-four patients received a burst of ketamine. Ten patients did not achieve any improvement. Pain intensity decreased from a mean of 7.8 (SD, 1.6) to 2.8 (SD, 1.3) (P<0.0005). The outcome was considered optimal, good, and mild in 24, 9, and 1 patients, respectively. Adverse effects attributable to ketamine did not have relevant intensity and no patient discontinued the treatment due to psychomimetic adverse effects. CONCLUSIONS This data suggests that a burst of ketamine and midazolam at low doses, may reverse an unfavourable opioid response, assisting the opioid switching. Although the role of ketamine remains controversial, it should not deter physicians to do not use that in specific conditions.