Carl Johan Fürst

Nausea in cancer chemotherapy is inversely related to urinary cortisol excretion

Treatment with corticosteroids can control mild to moderate emesis during chemotherapy (Cassileth et al., 1983) and adds to the antiemetic effect of high-dose metoclopramide in severe emesis (Bruera et al., 1983). Moreover, pregnancy induced nausea is more common among women with low than high cortisol excretion (Jarnfelt-Samsioe et al., 1986). These findings warrant an investigation whether endogenous cortisol secretion is associated with nausea induced by chemotherapy. The aim of the present study was to relate endogenous cortisol secretion to individual differences in chemotherapy induced nausea and vomiting. Urinary cortisol excretion remain stable over time, particularly during resting conditions (Forsman & Lundberg, 1982). Therefore, night time urine was collected to assay cortisol excretion. Self-reports were used to assess nausea and vomiting. Table I summarises the clinical features of the 21 consecutive outpatients and three inpatients receiving chemotherapy at the Karolinska Hospital who participated. None received high emetogenic cytostatics such as, for example, cisplatinum, and 12 subjects received no antiemetic treatment. Patients having received chemotherapy courses within

Awareness of husband's impending death from cancer and long-term anxiety in widowhood: a nationwide follow-up

Background: We investigated the predictors and long-term consequences of awareness time — the length of time a woman is aware of her husbands impending death from cancer. Methods: All women (n / 506) living in Sweden under 80 years of age who lost their husband/partner owing to cancer of the prostate in 1996 or of the urinary bladder in 1995 or 1996 were followed with an anonymous postal questionnaire, 2–4 years after their loss. Results: We received completed questionnaires from 379 of the widows. Of these, 55 (15%) reported an awareness time of 24 hours or less, 56 (15%) of 3–6 months and 95 (26%) of one year or more. The associations between the awareness time and morbidity were of a reverted ‘J-shape,’ with awareness time of 24 hours or less carrying the highest risk and 3–6/6–12 months the lowest. On comparing the awareness time of 24 hours or less with 3–6 months (preformed response category), the relative risks for anxiety were found to be 1.9 (1.0–3.6) (visual digital scale) and 4.5 (1.0–20.0) for intake of tranquillising drugs. Those not informed of their husbands fatal condition or not provided with psychological support by caregivers during their husbands last months of life had an increased risk of a short awareness time. Conclusions: During a mans terminal cancer illness, the wifes awareness time varies considerably and is influenced by information and psychological support from caregivers. A short awareness time may result in an additional and avoidable psychological trauma.

The use of corticosteroids in Swedish palliative care

Corticosteroids are commonly used in patients with advanced cancer on both specific and non-specific indications. They are potent drugs with potentially serious adverse side effects. We have in two separate surveys collected answers from 302 physicians and data from 1292 patients on corticosteroid prescription attitudes and clinical practice in Swedish palliative care. Corticosteroids were used in more than 50% of the cancer patients and with high response rates when treating appetite loss, nausea, fatigue or poor wellbeing. The positive response came within the first week of treatment and persisted beyond four weeks. Patients with prostate cancer had a significantly better treatment response of corticosteroids on fatigue as compared to patients with lung cancer. Few physicians had guidelines on the use of corticosteroids in advanced cancer and there were differences in the attitudes between different medical specialties. Guidelines based on prospective clinical trials are needed.

Long-term Harm of Low Preparedness for a Wife's Death From Cancer—A Population-based Study of Widowers 4–5 Years After the Loss

The authors examined the impact of a widowers preparedness before his wifes death from cancer on his risk of long-term morbidity. In a population-based study, 691 (76%) of 907 Swedish men who lost a wife to breast, ovarian, or colon cancer in 2000 or 2001 answered an anonymous questionnaire in 2004 or 2005 measuring preparedness at the time of the wifes death and psychological well-being at follow-up. Men aged 38-61 years with a low degree of preparedness at the time of their spouses death had increased risk of psychological morbidity and other symptoms, such as anxiety (adjusted relative risk (aRR) = 2.1, 95% confidence interval (CI): 1.0, 4.3), a heightened startle response (aRR = 5.3, 95% CI: 1.2, 23.6), emotional numbness (aRR = 2.1, 95% CI: 1.2, 3.6), little or no grief resolution (aRR = 2.7, 95% CI: 1.3, 5.4), and sleep disorders (aRR = 2.3, 95% CI: 1.2, 4.3), 4-5 years after the loss. For older widowers (aged 62-80 years), a low degree of preparedness increased the risk of having repeated painful memories (aRR = 2.8, 95% CI: 1.5, 5.2) and a heightened startle response (aRR = 5.7, 95% CI: 1.5, 21.4) at follow-up. These results show that to improve the long-term psychological well-being of widowers, it may be fruitful to identify care-related facilitators and inhibitors of preparedness.

Similarities and differences in assessing nausea on a verbal category scale and a visual analogue scale.

The use of verbal category scales in assessing patient symptoms is evolving, but the extent to which reliability and precision are lost in using them as opposed to a visual analogue scale (VAS) remains uncertain. The present study analyzed the concordance between a four-point verbal category scale and a VAS in assessing nausea intensity in patients undergoing chemotherapy. The analysis of a total of 348 simultaneous ratings by 104 women over four cycles revealed good concordance between the scales. The means of the VAS ratings (range 0-100 mm) corresponding to the four verbal categories divided the scale in four almost equally large parts (no nausea = 0.7, mild = 24.8, moderate = 48.3, severe = 75.1). However, the VAS ranges were wide. On an individual level a one-step change in the verbal category was associated with an average change of 20 mm on the VAS. The choice of scale to use should be based on the need in the particular situation. When measuring intensity of nausea in patients, the VAS is a reasonable choice due to its possibly greater ability to detect changes over time. On the group level, findings on a four-point category scale and a VAS on the average seem similar.

Long-term effects of widowhood after terminal cancer: a Swedish nationwide follow-up

Aims: The authors investigated whether becoming a widow after the death of a husband from cancer results in long-term psychological or physical morbidity. Method: In April and May 1999, an attempt was made to contact all of the 506 women who were living with men dying of prostate cancer in 1996 or of urinary bladder cancer in 1995 or 1996, as well as 287 population controls. Results: Completed questionnaires were received from 379 of the widows and 220 of the controls. Widowhood was associated with a low or moderate subjective quality of life (relative risk [RR]=1.4, 95% confidence interval 1.2—1.7), low or moderate psychological well-being (RR=1.8, 1.4—2.3), anxiety (RR=1.9, 1.3—2.7), depression (RR=2.2, 1.6—2.9), sleep disturbances (RR=1.9, 1.5—2.4), diabetes (RR=3.5, 1.2—7.9), and economic dissatisfaction (RR=1.6, 1.3—2.0). Conclusion: An excess risk of psychological morbidity, diabetes mellitus and dissatisfaction with the economic situation was found in the widowed population.

Developing a national quality register in end-of-life care: The Swedish experience:

Background: The complexity of end-of-life care, represented by a large number of units caring for dying patients, different types of organizations and difficulties in identification and prognostication, signifies the importance of finding ways to measure the quality of end-of-life care. Aim: To establish, test and manage a national quality register for end-of-life care. Design: Two questionnaires were developed with an attempt to retrospectively identify important aspects of the care delivered during the last week in life. An internet-based IT platform was created, enabling the physician and/or nurse responsible for the care during the last week in life to register answers online. Setting: Units caring for dying people, such as hospital wards, home care units, palliative in-patient care units and nursing facilities. Results: The register received status as a National Quality Register in 2006. More than 30,000 deaths in nursing facilities, hospital wards, palliative in-patient units and private homes were registered during 2010, representing 34% of all deaths in Sweden and 58% of the cancer deaths. Conclusions: We have shown that it is feasible to establish a national quality register in end-of-life care and collect data through a web-based system. Ongoing data analyses will show in what way this initiative can lead to improved quality of life for patients and their families. There is an ongoing process internationally to define relevant outcome measures for quality of care at the end-of-life in different care settings; the registry has a potentially important role in this development.

Suicide among patients with amyotrophic lateral sclerosis

Studies on the suicide risk among patients with amyotrophic lateral sclerosis (ALS) in countries without legalized euthanasia or assisted suicide are important additions to data on the wish to die of these patients. We conducted a population-based cohort study in Sweden between 1965 and 2004, which comprised of 6,642 patients with incident ALS identified from the Swedish Inpatient Register. We calculated the standardized mortality ratios (SMRs) of suicide among the patients using the suicide rates of the general Swedish population as a reference. In total, 21 patients committed suicide during follow-up, compared to the predicted 3.6 suicides. Thus, we noted an almost 6-fold increased risk for suicide among ALS patients [SMR 5.8, 95% confidence interval (CI) 3.6-8.8]. Patients who committed suicide were, on average, around 7 years younger at the time of their first period of hospitalization than patients who did not commit suicide. The highest relative risk for suicide was observed within the first year after the patients first period of hospitalization (SMR 11.2, 95% CI 5.8-19.6). After that, the relative risks decreased with time after hospitalization (P-value for trend = 0.006), but remained elevated 3 years later. The relative risks of suicide among ALS patients did not show a clear trend over time in contrast to the decreasing trend of relative risks for suicide among patients with cancer during the same period. Patients with ALS are at excess risk of suicide in Sweden and the relative risk is higher during the earlier stage of the disease.

Dimensions of Fatigue during radiotherapy : An application of the Swedish Occupational Fatigue Inventory (SOFI) on cancer patients

The aims of this study were primarily to evaluate the applicability of the Swedish Occupational Fatigue Inventory (SOFI) on cancer patients, secondly to describe the development of fatigue in patients, receiving full dose radiotherapy with a curative intent. A questionnaire was completed by 81 cancer patients at four occasions; before treatment. during the last week of treatment. 1 and 3 months, respectively, after treatment. The fatigue increased significantly at the end of treatment, as compared to pretreatment, and decreased after treatment. The highest fatigue ratings concerned lack of energy, lack of motivation and sleepiness. The five SOFI-dimensions explained more than half of the variance in the overall rating of fatigue, and the internal consistency of the dimensions were good. However, the ratings were on the lower part of the scale and the dimensions correlated more than expected. Thus, the relevance of the SOFI for use also among patients is only partially supported, and studies with larger samples are needed for further testing of the inventory.The aims of this study were primarily to evaluate the applicability of the Swedish Occupational Fatigue Inventory (SOFI) on cancer patients, secondly to describe the development of fatigue in patients, receiving full dose radiotherapy with a curative intent. A questionnaire was completed by 81 cancer patients at four occasions; before treatment, during the last week of treatment, 1 and 3 months, respectively, after treatment. The fatigue increased significantly at the end of treatment, as compared to pretreatment, and decreased after treatment. The highest fatigue ratings concerned lack of energy, lack of motivation and sleepiness. The five SOFI-dimensions explained more than half of the variance in the overall rating of fatigue, and the internal consistency of the dimensions were good. However, the ratings were on the lower part of the scale and the dimensions correlated more than expected. Thus, the relevance of the SOFI for use also among patients is only partially supported, and studies with larger samples are needed for further testing of the inventory.

Complexity in Non-Pharmacological Caregiving Activities at the End of Life: An International Qualitative Study

In a qualitative study reported by Olav Lindqvist and colleagues, the range of nonpharmacological caregiving activities used in the last days of a patients life are described.