Claudio Cartoni

Pain syndromes in the setting of haematopoietic stem cell transplantation for haematological malignancies.

Severe pain syndromes may be recorded during all phases of haematopoietic stem cell transplantation (HSCT) for haematological malignancies: from stem cell mobilization to the long-term post transplant period. Although the major cause of pain in the setting of HSCT is injury to mucosal tissues induced by the conditioning regimen, pain from several other causes has been reported. In this paper, we review pain and its management in the setting of HSCT.

Hemorrhagic complications in patients with advanced hematological malignancies followed at home: an Italian experience.

Patients with advanced hematological malignancies may experience many troublesome hemorrhagic complications requiring hospitalisation during a palliative home care (HC) program. We report on the feasibility of the management of bleeding at home in patients with haematological malignancies admitted in a domiciliary HC program. The occurrence of a major hemorrhage episode (>1 WHO grade) was registered among 469 patients with hematological malignancies in the terminal phase of their disease followed at home. Number, sites, domiciliary treatment (local hemostatic measures, platelet units, hemostatic drugs, packed red blood cells) and outcome of hemorrhagic complications were evaluated. Out of 469 patients, 123 (26%) experienced a bleeding complication; the overall number of hemorrhagic episodes was 232 (49%) with a median number of 2 episodes per patient. Patients with a platelet count lower than 20 × 109/L (P < 0.00005) or with a diagnosis of acute leukemia or in blast crisis of myeloprolypherative disorders (P < 0.00005) showed a significant higher incidence of hemorrhages than other patients. Resolution of bleeding at home was obtained in 206 (88%) of the 232 episodes; platelet units were transfused at home in 188 (81%) cases. Bleeding was the cause of hospitalisation in four cases. Death occurred in 447 of 469 patients: in 26 of them (6%), it was caused by bleeding complications (11 brain hemorrhage, 2 hematemesis, 3 hemoptysis and 10 melena). In this group of patients, bleeding was a relevant clinical problem However, by implementing a domiciliary palliative care program, home management of hemorrhages proved to be a safe and effective choice.

Prevalence of oral mucositis, dry mouth, and dysphagia in advanced cancer patients.

BackgroundOral symptoms can be a sign of an underlying systemic condition and have a significant impact on quality of life, nutrition, and cost of care, while these lesions are often studied in the context of cancer treatment. However, information regarding oral symptoms in advanced cancer patients is poor. The aim of this multicenter study was to determine the prevalence and the characteristics of oral symptoms in a large population of advanced cancer patients.MethodsA consecutive sample of patients with advanced cancer for a period of 6xa0months was prospectively assessed for an observational study. At time of admission, the epidemiological characteristics, surgery-radiotherapy of head and neck, and oncologic treatments in the last month were recorded. The presence of mucositis, dry mouth, and dysphagia was assessed by clinical examination and patients’ report and their intensity recorded. Patients were also asked whether they had limitation on nutrition of hydration due to the local condition.ResultsSix hundred sixty-nine patients were surveyed in the period taken into consideration. The mean age was 72.1xa0years (SD 12.3), and 342 patients were males. The primary tumors are listed in Tablexa01. The prevalence of mucositis was 22.3xa0%. The symptom relevantly reduced the ingestion of food or fluids and was statistically associated with the Karnofsky level and head and neck cancer. The prevalence of dry mouth was 40.4xa0%, with a mean intensity of 5.4 (SD 2.1). Several drugs were concomitantly given, particularly opioids (78xa0%), corticosteroids (75.3xa0%), and diuretics (70.2xa0%). Various and nonhomogeneous treatments were given for dry mouth, that was statistically associated with current or recent chemotherapy, and hematological tumors. The prevalence of dysphagia was 15.4xa0% with a mean intensity of 5.34 (SD 3). Dysphagia for liquids was observed in 52.4xa0% of cases. A high level of limitation for oral nutrition due to dysphagia was found, and in 53.4xa0% of patients, alternative routes to the oral one were used. Dysphagia was statistically associated with the Karnofsky level and head and neck cancer. A strong relationship between the three oral symptoms was found.ConclusionIn advanced cancer patients, a range of oral problems significantly may impact on the physical, social, and psychological well-being of advanced cancer patients to varying degrees. These symptoms should be carefully assessed early but become imperative in the palliative care setting when they produce relevant consequences that may be life-threatening other than limiting the daily activities, particularly eating and drinking.

Pain management in multiple myeloma.

Pain is a prominent feature of multiple myeloma (MM) and may be caused by different underlying causes and mechanisms. Indeed, pain may be due to disease-related complications, iatrogenic causes or may be associated with other unrelated medical conditions. This symptom may be particularly devastating and can negatively affect the quality of life of the afflicted patients and their functional status. For most MM patients suffering from continuous nociceptive pain, the WHO’s three-step analgesic ladder can provide adequate relief with oral options, although the high prevalence in MM patients of difficult-to-treat pains, such as pains due to skeletal mechanical instability or sustained by neuropathic mechanisms, makes the treatment approach a challenging concern. The management of pain in this setting requires a multidisciplinary approach integrating analgesics and causal interventions. This review focuses on the most common syndromes afflicting MM patients, attempting to provide an understanding of the underlying pain mechanisms and a discussion of the most commonly used treatment strategies.

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

CONTEXTnInformation regarding sleep disturbances in the population with advanced cancer is meager.nnnOBJECTIVESnTo 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.nnnMETHODSnThis 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).nnnRESULTSnA 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.nnnCONCLUSIONnMore 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.

Predicting survival in advanced hematologic malignancies: do patient-reported symptoms matter?

To investigate whether patient‐reported symptoms provide independent prognostic information for survival in patients with hematological malignancies.

Epidemiology and Characteristics of Episodic Breathlessness in Advanced Cancer Patients: An Observational Study

CONTEXTnEpisodic breathlessness is a relevant aspect in patients with advanced cancer.nnnOBJECTIVESnThe aim of this study was to assess the different aspects of this clinical phenomenon.nnnMETHODSnA consecutive sample of patients with advanced cancer admitted to different settings for a period of six months was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity (numerical scale 0-10), and drugs used for treatment were collected. Factors inducing episodic breathlessness and its influence on daily activities were investigated.nnnRESULTSnOf 921 patients, 29.3% (nxa0=xa0269) had breathlessness and 134 patients (49.8%) were receiving drugs for background breathlessness. In the multivariate analysis, the risk of breathlessness increased with chronic obstructive pulmonary disease, although it decreased in patients receiving disease-oriented therapy and patients with gastrointestinal tumors. The prevalence of episodic breathlessness was 70.9% (nxa0=xa0188), and its mean intensity was 7.1 (SD 1.6). The meanxa0duration of untreated episodic breathlessness was 19.9xa0minutes (SD 35.3); 41% of these patients were receiving drugsxa0for episodic breathlessness. The majority of episodic breathlessness events (88.2%) were triggered by activity. In the multivariate analysis, higher Karnofsky Performance Status levels were significantly related to episodic breathlessness, although patients receiving disease-oriented therapy were less likely to have episodic breathlessness.nnnCONCLUSIONnThis study showed that episodic breathlessness frequently occurs in patients with breathlessness in the advanced stage of disease, has a severe intensity, and is characterized by rapid onset and short duration, which require rapid measures.

Carbapenem-resistant Klebsiella pneumoniae in high-risk haematological patients: factors favouring spread, risk factors and outcome of carbapenem-resistant Klebsiella pneumoniae bacteremias

BackgroundCarbapenem-resistant Klebsiella pneumoniae (CRKP) spread and infections in patients with haematological malignancies are a serious concern especially in endemic areas. Treatment failures and delay in appropriate therapy for CRKP infections are frequent and the mortality rate associated with CRKP bacteremia in neutropenic haematological patients is reported about 60%.MethodsHaematological patients harboring CRKP hospitalized between February 2012 and May 2013 in an Italian Teaching hospital were examined. Conditions favouring CRKP spread in a haematological unit, risk factors for bacteremia in CRKP-carriers and for CRKP bacteremia-related death were evaluated in this observational retrospective study.ResultsCRKP was isolated in 22 patients, 14 (64%) had bacteremia. Control measures implementation, particularly the weekly rectal screening for CRKP performed in all hospitalized patients and contact precautions for CRKP-carriers and newly admitted patients until proved CRKP-negative, reduced significantly the CRKP spread (14 new carriers identified of 131 screened patients vs 5 of 242 after the intervention, pu2009=u20090.001). Fifty-eight percent of carriers developed CRKP bacteremia, and acute myeloid leukemia (AML) resulted independently associated with the bacteremia occurrence (pu2009=u20090.02). CRKP bacteremias developed mainly during neutropenia (86%) and in CRKP-carriers (79%). CRKP bacteremias were breakthrough in 10 cases (71%). Ten of 14 patient with CRKP bacteremias died (71%) and all had AML. The 70% of fatal bacteremias occurred in patients not yet recognized as CRKP-carriers and 80% were breakthrough. Initial adequate antibiotic therapy resulted the only independent factor able to protect against death (pu2009=u20090.02).ConclusionsThe identification of CRKP-carriers is confirmed critical to prevent CRKP spread. AML patients colonized by CRKP resulted at high risk of CRKP-bacteremia and poor outcome and the adequacy of the initial antibiotic therapy may be effective to improve survival. To limit the increase of resistance, the extensive use of antibiotics active against CRKP should be avoided, but in the setting of high CRKP pressure and high-risk CRKP-colonized haematological patients, timely empiric antibiotic combinations active against CRKP could be suggested as treatment of febrile neutropenia.

Accidental falls in home care hematological patients

Dear Editor, Accidental falls are a major concern in patients with both medical and surgical illness for twomain reasons: (1) potential complications, such as bone fractures, leading to hospitalization requirement and direct or indirect cost increase; (2) medico-legal and insurance implications of a fall and its complications, above all in controlled environments, such as hospital wards, nursing homes, and home care (HC). HC management is a special area of application in advancedterminal onco-hematological and older hematological patients, which is concerned with several factors, such as difficulty with access to a hospital and obtaining considerable benefits from HC, when compared with inpatient management. HC management allows the assistance of hematological patients at home, furnishing the health services that usually would be supplied in a hospital to treat hematological diseases and their complications (e.g., medical examinations, blood tests, transfusions, chemotherapy, etc.) [1–3]. Hematological patients, due to the underlying disease, their treatment, or associated comorbidities, are faced with several pathological processes, which may increase the risk of accidental falls in comparison to the general population. Risk factors for accidental falls have been extensively analyzed, both in the general population (children [4], elderly [5]) and in certain diseases (dialysis [6], stroke [7], cancer [8]), as well as in various settings (such as hospitals [9] and nursing homes [10]). An extensive literature search was conducted through database scanning, revealing lack of evidence regarding falls and injury in hematological HC patients. HC hematological patients could be considered at high risk both for accidental falls (due to age [8] and clinical features, such as anemia [11], fatigue, disability [12–16], cognitive impairment [17], and drugs [18, 19]), and for subsequent complications, such as fractures (due to osteolysis, treatment-induced/enhanced osteoporosis [20]), bleeding (due to hemostasis disorders), and infection. The aim of the present study was to retrospectively evaluate fall frequency and fall injury in hematological HCmanaged patients. Clinical data of 193 patients admitted in our HC service from January 2010 to June 2011 (median follow-up, 74 days (range, 15–500)) were retrospectively reviewed. Among these, 133 patients, with properly recorded clinical data, were considered evaluable for further analysis; 60 patients were excluded due to incomplete data recording (e.g., lack of registration of physical examination data). Accidental fall events (defined as “unexpected descent to the floor”) were extracted and analyzed, as well as complications and their outcome. Evaluable patient data were the following: 54 males (41 %), 79 females (59 %); diagnosis and disease stage are shown in Table 1. Median age was 83 years (20–98); age range details are shown in Table 2. Twenty-six fall events were identified in 23/133 pts (17 %). A total of 18,886 days A. Tendas : L. Cupelli :M. M. Trawinska : L. Lentini Hematology Unit, S. Eugenio Hospital, Home Care Service of the Rome Section of the Italian Association Against Leukemias (RomAIL), Rome, Italy

Homecare-based motor rehabilitation in musculoskeletal chronic graft versus host disease

Chronic graft versus host disease (cGVHD) is a frequent complication of allogeneic stem cell transplantation. Extensive musculoskeletal and skin involvement may induce severe functional impairment, disability and quality of life deterioration. Physical rehabilitation is recommended as ancillary therapy in these forms, but experiences are sparse. A 39-year-old man affected by musculoskeletal and skin chronic graft versus host disease (cGVHD) was treated with a homecare-based motor rehabilitation program during palliation for disease progression. Significant functional improvement was obtained. Motor rehabilitation should be strongly considered for patients with musculoskeletal cGVHD, both in the palliative and in the curative phase of disease.