Gregorio Antonio Brunetti

Epidemiology, features and outcome of pain in patients with advanced hematological malignancies followed in a home care program: an Italian survey

We report on epidemiology, features, outcome, and domiciliary management of pain in patients with advanced hematological malignancies followed by an experienced hospital-based home care (HC) team. Out of 469 patients, 244 (52%) experienced a total of 284 pain syndromes. Pain intensity was rated from mild to moderate in 31% and from moderate to severe in 69% of them. The diagnosed pain mechanisms were deep somatic in 56%, superficial somatic in 15%, visceral 14%, mixed 8%, and neuropathic in 7% of pain syndromes, respectively. Incident pain was observed in 38% of all pain syndromes. In every diagnostic group, deep somatic pain was prevalent. Moreover, 85% of visceral pain syndromes were observed in patients affected by non-Hodgkin’s lymphoma (NHL). In addition, out of 284 pain syndromes, 150 (51%) were caused by bone involvement. The most frequent recognized pain provocative mechanisms were bone marrow expansions, osteolysis, lymph node enlargement, and mucositis. In our experience, an approach based on the association of causal therapies and analgesics allows optimal control of most pain syndromes. Therefore, pain is a major problem in patients affected by advanced hematological malignancies, and its management can be effective and feasible when carried out by a skilled HC team.

Pain and anxiety associated with bone marrow aspiration and biopsy: a prospective study on 152 Italian patients with hematological malignancies

Dear Editor, Pain and anxiety associated with bone marrow aspiration and biopsy (BMAB) are frequently encountered by hematologists in daily clinical practice [1–5], about which we have read with much interest what was reported by Degen and colleagues in a previous issue of the journal [6]. In order to address this issue, we have performed a singlecenter prospective survey on patients affected by hematological malignancies (HM) and submitted to BMAB. Between January and June 2010, pain and anxiety were assessed in all adult patients who underwent BMAB. There were 152 HM patients (M/F) with a median age of 54 years (range, 22–91). The main demographic data, hematological diagnoses, and procedure characteristics are reported in Table 1. A careful clinical assessment, including examination of past medical history, allergies, mental status, and review of current medications was performed before the procedure. Adequate information about the scope and indication of the invasive diagnostic maneuver and about all the steps involved in performing it were given by the hematologists at their best; again, patients were invited to formulate any questions about the procedure. All patients were properly informed and gave their written consent to participate in the study. In accordance with our institutional standard operating procedures, BMAB was performed under local anesthesia with 5 ml of lidocaine hydrochloride 1% aqueous solution in the left and/or right posterior superior iliac crest by a skilled hematologist with adequate technical experience. Other than local anesthesia, no other premedication was given. Anxiety before and pain during the procedure were assessed by patient interview 10 min before and 10 min after the procedure, respectively. A numerical rating system (NRS) scale, ranging from 0 (no symptom) to 10 (the worst), was administered to score symptom intensity. In order to explore correlation between anxiety before and pain during the procedure, the incidence of moderate–severe pain (NRS=4–10) in different anxiety severity populations of the cohort was examined. Statistical analysis was performed using Pearsons chi-square test. All 152 patients were evaluable for analysis (Table 2). Anxiety was experienced by 108/152 (71%) patients and scored as mild (1–3), moderate (4–7), and severe (8–10) in 29 (27%), 47 (44%), and 32 (29%) of them, respectively; median anxiety NRS value was 4 (range, 0–10). Pain was reported in 118/152 (78%) patients and scored as mild (1–3), moderate (4–6), and severe (7–10) in 63 (53%), 41 (35%), and 14 (12%) of them, respectively; median pain NRS value was 3 (range, 0–10). By using median anxiety NRS G. A. Brunetti (*) : E. Meloni :D. Mancini : P. Maggiore : C. Cartoni :G. Alimena Division of Hematology, Department of Cellular Biotechnologies and Hematology, University “La Sapienza”, Rome, Italy e-mail: brunetti@bce.uniroma1.it

Disability and physical rehabilitation in patients with advanced hematological malignancies followed in a home care program

Dear Editor, Hematological malignancies (HM) in their advanced course may be progressively complicating by debilitating deteriorations of the personal status, physical deconditioning, and several forms of motor disability (MD), often leading to severe limitations in performing activities of daily living and in the loss of the individual independence. Although hematologists are faced with problems arising from functional decline in their daily clinical practice, little information about the exact burden of disability in the HM setting are available, and very few experiences on the role of physical rehabilitation, a part of the management of these patients, have been reported [1, 2]. In order to address this issue, we evaluated the incidence of MD and the feasibility of a rehabilitation program in a group of patients with advanced HM followed by a specialized home care service [3–5]. In this regard, MD was assessed monthly using Barthel index (BI) [6] and was classified as: mild (BI>66%), moderate (BI: 33–66%), and severe (BI<33%). Patients with a BI reduction and life expectancy of more than 3 months were evaluated for a rehabilitative home-based program. Exclusion criteria were: patient refusal, contraindications to mobilization (untreatable osteolytic lesions and skeletal instability), moderate to severe respiratory insufficiency, and severe cognitive impairment. Rehabilitative program was tailored on patient target; feasibility of the program was evaluated by assessing the administered-intensity/planned-intensity ratio. From April 2008 to February 2009, 136 patients entered the study. Median age was of 81 (range, 25–96), 84 males and 52 female. Diagnoses were as follows: acute leukemia, 31; lymphoma/chronic lymphocytic leukemia, 24; multiple myeloma, 13; myelodysplastic/myeloproliferative disorders, 50; and other diagnosis, 18. Out of 136 evaluable patients, 52, 60, 11, 5, and 8 were patients in advanced disease, chronic disease, complete/partial remission (CR/PR), relapse/progression/new diagnosis, and undefined status, respectively. MD was observed in 122/136 patients (90%), being mild, moderate, and severe in 48/122 (39%), 46/122 (38%), and 28 (23%), respectively. Given the burden of disability recorded by us, a pilot interventional study was launched, and 18 patients were offered a rehabilitation program; out of these, three were not eligible, while 15 patients (nine male) with a median age of 75 (range, 37–92) received the planned treatment. Among them, five patients were affected by multiple myeloma, four by myelodysplastic syndromes, two by acute myeloid leukemias, and four by A. Tendas : P. Niscola (*) :M. Ales : L. Baraldi : C. Boschetto : E. Caiazza : L. Cupelli :M. Giovannini : L. Scaramucci : P. de Fabritiis Hematology Unit, S.Eugenio Hospital, Rome, Italy e-mail: pniscola@gmail.com

Transfusions at home in patients with myelodysplastic syndromes

We report descriptive data of a home care (HC) program, throughout a 5-years period (2006-2010), focusing on the reliability and the safety of transfusions at home in 211 patients affected by myelodysplastic syndromes (MDS). Our results outline the potentially relevant role of a specifically dedicated HC service in the global management of frail MDS patients for which transfusions at home may represent a valuable option to maintain a good quality of life and avoid the possible discomfort due to hospital admissions and outpatient visits.

Anticoagulant and Anti-thrombotic Treatments in the Management of Hematological Malignancies in a Home Care Program

Aim: Anticoagulants (AC) and anti-platelet (AP) agents are widely administered to patients with hematological malignancies (HM). However, HM patients may be at high risk of bleeding and hemorrhagic complications, because of different form of coagulopathies and several degrees of thrombocytopenia. Materials and Methods: A prospective evaluation of the use of anticoagulant and anti-thrombotic agents as well as of bleeding and thrombotic complications in a consecutive cohort of patients, which were followed during the first semester of 2010 by our home care service, was performed. In this regard, three pharmacological class of agents, such as oral anticoagulants (warfarin and acenocumarine), low molecular weight heparin (LMWH) and anti-platelet (AP) drugs were considered. Results: Out of 129 patients, 26 (20%) were treated with AC/AP drugs. Warfarin, acenocumarine, LMWH as well as AP were used in 7, 11 and 12 patients, respectively. Adverse events (bleeding) were observed in 3 patients (11.5%), 2 cases being on warfarin (replaced by LMWH) and 1 being AP (suspension without replacement); out of the 3 patients with bleeding, none presented thrombocytopenia. Conclusions: Despite the frequent findings of hemostatic disorders in a population of frail patients managed in a home care setting, our experience demonstrated that the use of AC/AP drugs has been very rarely responsible for significant complications.

Pain in malignant hematology

Pain is frequently experienced by patients with hematological malignancies, although it often receives little attention. Different underlying causes and mechanisms may sustain several pain syndromes in hematological malignant patients. Pain may be due to disease itself, to disease-related complications, to iatrogenic causes or may be associated with unrelated medical conditions. The management of pain in this setting requires a multidisciplinary approach, integrating analgesics and causal interventions. An accurate diagnostic assessment and the identification of the underlying causes and pathogenetic mechanisms may dictate the treatment approach. For most pain patients, the WHO’s three-step analgesic scale for cancer pain relief can provide adequate relief with oral options, although difficult-to-treat pain syndromes, requiring a more complex treatment approach, may also be observed.

Management of hematological malignancies in patients affected by renal failure

The management of hematological malignancies (HM) in renally impaired patients may be a difficult task. Indeed, the kidney represents a major elimination pathway for many chemotherapeutic agents and their metabolites, whose serum levels are not usually measured in daily clinical practice. In addition, many antineoplastic drugs have a narrow therapeutic index for which they require dose adjustment when administered to patients with renal failure. Only limited data regarding the use of chemotherapy in patients with renal impairment and in those on dialysis are available. Indeed, renal patients with HM are often excluded from most clinical trials. Thus far, in order to provide recommendations, we have reviewed the pertinent literature, gathering information from published guidelines regarding chemotherapy in patients with kidney dysfunction and from articles describing the use of individual agents in renal patients with HM.

Tapentadol PR for Pain Syndromes in Real Life Patients with Hematological Malignancy

BACKGROUND More than 50% of oncohematological patients suffer from pain syndrome, mostly originating from the bone, which often include nociceptive and neuropathic complaints. Tapentadol, a recently available treatment option for cancer pain, exerts a dual analgesic mechanisms (opioid and noradrenergic), allowing for a high clinical efficacy as well as for a reduction in adverse events compared to traditional opioids. AIM To explore the safety and efficacy of tapentadol as a suitable agent for the pain management in the setting of oncohematology. METHODS Our observational study included 36 patients with basal pain intensity (NRS) ranging from 5 to 10. Tapentadol prolonged release (PR) was given at the initial dose of 50 mg BID and careful titrated according to the achieved pain control. RESULTS Tapentadol PR was given at the dosages ranging from 200 and 260 mg/day after a careful titration, allowed for a clinically (-7 points NRS) remarkable reduction of pain intensity without any significant side effects. CONCLUSION In oncohematological patients on pain, tapentadol PR was effective and well tolerated, so representing a suitable treatment option in this difficult setting.

Pain Management in Hematological Patients with Major Organ Dysfunctions and Comorbid Illnesses

BACKGROUND Organ dysfunctions and medical complications, such as renal failure, liver impairment, coagulation disorders, cardiovascular and respiratory illnesses, may hamper an adequate pain management in haematological patients. AIM To summarize current knowledge on pain management in hematological patients presenting major organ dysfunctions and comorbidity. We also attempted to provide recommendations to optimize analgesia and to minimize side effects in the setting of medically compromised and frail haematological patients. METHODS A systematic search of the literature, using relevant key words, was conducted in PubMed. RESULTS AND CONCLUSIONS Pain in hematological patients is a common symptom and is often multi-factorial. Most pharmacotherapeutic measures, including causal therapies, analgesics and adjuvant agents routinely applied in pain management, may also be used in the setting of clinical frailty and medical comorbidities; however, comprehensive clinical and functional patients evaluations and a careful consideration of expected benefits and potential adverse events are required.

Management of the 2009 A/H1N1 Influenza Pandemic in Patients with Hematologic Diseases: A Prospective Experience at an Italian Center

Data derived from epidemiologic surveillance adopted at our center in hematologic and stem cell transplant patients during the 2009 influenza A (H1N1)v pandemic are reported. Of the 52 patients with influenza-like disease we observed, 37 underwent a real-time PCR evaluation and 21 had a confirmed diagnosis. Of the RT-PCR-confirmed cases, 23.8% were children (age <18 years) and 9.5% were >65 years; 47.6% presented with a pulmonary infiltrate and 33.3% with respiratory failure. Pulmonary involvement was observed more frequently in patients with comorbidities. All patients received a course of oseltamivir therapy starting an average of 1 day (range <1–2) after the onset of symptoms. No patient was transferred to the intensive care unit. The viral disease had a generally favorable outcome despite the high frequency of pulmonary involvement. A prompt clinical evaluation with an early antiviral and supportive therapy may have played a beneficial role in the outcome.