Irene Panagiotou

Intranasal fentanyl: from pharmacokinetics and bioavailability to current treatment applications.

Fentanyl, a short-acting synthetic pure opiate, offers an excellent option for the treatment of cancer and chronic pain. While oral administration is not an option, its high potency and lipophilicity have made intranasal administration feasible. Intranasal fentanyl has a bioavailability of 89%, with a short onset of action (∼7 min) and duration times (∼1 h). It bypasses the oral/gastrointestinal route, delivers the analgesic dose in a volume of 150 µl that can be adequately absorbed and, with a pH of 6.4, avoids local irritation. Intranasal fentanyl has been investigated to assess its potential as a well-tolerated acute postoperative breakthrough pain relief medication. It has been shown to be superior to oral transmucosal fentanyl for the treatment of cancer breakthrough pain. Similar analgesic effects to fentanyl or morphine intravenously and orally, with a similar safety profile, have been reported for postoperative or acute pain treatment of children and adults in the prehospital and hospital settings.

Self-Efficacy, Depression, and Physical Distress in Males and Females With Cancer

Aims: To examine the relationship between self-efficacy with depression and physical distressing symptoms in males and females with cancer. Methods: A total of 41 males and 49 females with cancer completed the General Perceived Self-Efficacy Scale (GSE), depression scale, from the Hospital Anxiety and Depression Scale (HAD-D), and the MD Anderson Symptom Inventory (MDASI). Results: Correlations were found between depression and self-efficacy in males (r = -.501, P = .001) and females (r = -.588, P < .0005). The multivariate regression analysis revealed that education and depression could influence self-efficacy in male population. Urogenital versus breast cancer as well as depression seemed to influence females’ self-efficacy. Conclusions: Patients who had higher self-efficacy had lower depressive symptoms. Men with depressive symptoms and women with breast cancer and depression are more likely to have low self-efficacy than patients with other cancer types.

Non-Analgesic Effects of Opioids: Opioids’ Effects on Sleep (Including Sleep Apnea)

The exact effect of opioid analgesics on sleep is to be determined. Although literature data are sporadically reported, the aim of this review is to summarize the already known effects of such medications on sleep. A variety of effects, both positive and negative, has been suggested, when opioids are used for pain treatment, but in the absence of pain as well. Although often thought to promote restful sleep, the reality is much more complicated. Sleep disturbances and alterations of sleep quantity and quality have been reported. In addition, their sedative effects have been relatively well established and opioids can cause respiration to slow and become irregular, leading to hypercapnia and hypoxia. As a result, their usage has been linked to irregular or ataxic breathing (Biots breathing) and their use has been associated with both central and obstructive sleep apnea. One could estimate that central apnea is a common complication of such chronic therapy, affecting between 30% and 90% of patients. Thus, sleep disturbances can be induced or deteriorated. On the other hand, extended release opioid formulations have been suggested to improve sleep due to no analgesic gaps and less walking because of breakthrough pain. Furthermore, several reports have shown significantly improved sleep quantity and adequacy, with reduced sleep disturbances. Still, as no prospective trials on the effect of opioid therapy on sleep are available and evidence is scarce, definitive conclusions cannot be drawn. Future studies with their effect on sleep as primary end-point are needed to draw permanent conclusions.

Fentanyl nasal spray for the treatment of cancer pain

Introduction: Breakthrough pain, a transitory flare of pain in patients with otherwise controlled chronic pain, has been well characterized in cancer patients but despite medical awareness, sometimes remains underdiagnosed and therefore undertreated. Areas covered: Oral transmucosal fentanyl citrate (OTFC) and fentanyl buccal tablets are the first medications developed specifically for the treatment of breakthrough pain in opioid-tolerant patients. Since oral administration of fentanyl is not an option for many cancer patients, the development of intranasal fentanyl spray (INFS) emerged as a more effective method of administration. Intranasal administration of fentanyl has several advantages over the oral/gastrointestinal route and clinical trials have shown that it is superior to OTFC while being well tolerated and more acceptable by the majority of patients. Expert opinion: The aim of this review is to summarize the pharmacological characteristics and data obtained from clinical studies of INFS in the past few years, and present Fentanyl Pectin Nasal Spray (PecFent), which uses an innovative delivery system and is now approved in the EU. Finally, we discuss the impact that it may have in the future management of breakthrough pain in cancer patients, because an accurate diagnosis followed by the best treatment is crucial for effective pain alleviation.

Geriatric depression in advanced cancer patients: The effect of cognitive and physical functioning

Aim:  The aims of the current study were to evaluate geriatric depression and its risk factors in advanced cancer patients.

Traumatic Experiences of Patients With Advanced Cancer

The purpose of this study was to investigate posttraumatic stress disorder (PTSD) in advanced cancer patients, their reported traumatic experiences, and the relationship between patients with PTSD and non-PTSD as well as between cancer as trauma versus other traumatic experiences. A descriptive analysis revealed that 195 advanced cancer patients had anxiety disorders; 170 had PTSD, while 25 had other anxiety disorders. The majority of the patients (66.7%) with PTSD reported that their cancer diagnosis was the traumatic event for them. In addition, 10.8% reported that they had experienced a death of a loved one, and the rest (22.5%) reported other traumatic events. Death of a loved one and cancer seemed to be the most traumatic events for patients in advanced stages of cancer, and thus psychotherapeutic treatment is essential.

A test of the psychometric properties of the cancer locus of control scale in Greek patients with advanced cancer

The study aimed to assess the psychometric properties of the Cancer Locus of Control (CLOC) scale on a Greek sample of advanced cancer patients.

The Mediation Effect of Anxiety Between Post-Traumatic Stress Symptoms and Preparatory Grief in Advanced Cancer Patients

CONTEXT The relationship between anxiety and preparatory grief is complex and poorly understood. OBJECTIVES To investigate the relationship between anxiety, post-traumatic stress symptoms, and preparatory grief in a sample of patients with advanced cancer. METHODS Ninety-four patients with advanced cancer completed the Greek version of the Impact of Events Scale-Revised (IES-R-Gr), the Anxiety subscale of the Greek Hospital Anxiety and Depression Scale, and the Preparatory Grief in Advanced Cancer Patients (PGAC) scale. RESULTS Statistically significant associations were found between IES-R-Gr subscales, anxiety (P<0.0005), and PGAC (P<0.0005). CONCLUSION Some of the effect of post-traumatic stress symptoms on preparatory grief is mediated by anxiety.

Recanalization of Dialysis Catheter-Related Subclavian Vein Occlusion Using a Re-Entry Device: Report of Two Patients

Dialysis in patients with end-stage renal disease should be performed using a timely placed permanent access. A structured approach to choosing the type and location of long-term access should help optimize access survival and minimize complications. Good surgical practice mandates that one should always consider the most distal site possible to permit the maximum number of future possibilities for access. A peripheral-to-central sequence of fistulae construction should be envisioned, beginning with the ‘‘snuff box’’ fistula at the base of the thumb, followed by the standard Brescia-Cimino wrist fistula, followed by a forearm cephalic fistula at the dorsal branch, and, finally, a mid-forearm cephalic fistula. If a forearm fistula is not feasible, an antecubital fistula, and, finally, a transposed basilica fistula should be considered. If a graft is constructed, preference should be given to the following sequence: forearm loop; upper arm, straight or curved; then upper-arm loop. All upper-extremity options should be considered before using the thigh. In all situations, a systematic radiologic evaluation of the venous systems should be conducted before placement [1]. However, many patients undergo central vein catheter placement for dialysis purposes before the creation of the shunt. It is estimated that as many as 40% of these patients will develop subclavian vein stenosis or occlusion [2]. If the shunt is created in the arm ipsilateral to the subclavian vein lesion, the patient will experience arm swelling, pain, and increased recirculation because of the sudden increase in venous pressure. Interventional treatment is the mainstay of therapy of these lesions [3]. If standard interventional techniques fail, sharp needle recanalization technique has been used in small numbers of patients with good results [4]. We describe an alternative method in two dialysis patients, in whom difficult-to-cross subclavian vein occlusions were successfully recanalized with the use of a re-entry device.

Well-differentiated hand liposarcoma with bone metastases treated successfully with zoledronic Acid.

Background: Well-differentiated liposarcomas of the upper extremities, such as the hand or forearm, are extremely rare and are commonly misdiagnosed and considered benign. They are frequently reported as having low metastatic potential. Case Report: We report the case of a 58-year-old man with well-differentiated hand liposarcoma and diffuse bone metastases. The patient initially presented with a tumor of the thenar eminence and was treated with marginal surgical excision and external beam irradiation. 4 months after this treatment, soft tissue local recurrence and skeletal metastases were detected. Zoledronic acid treatment (4 mg per month) was initiated, and both the tumor and the metastases regressed. The patient remains cancer-free 3.5 years after diagnosis of the metastatic disease. Conclusion: Significant metastatic disease can develop in patients with well-differentiated liposarcomas. The beneficial effect of zoledronic acid observed in this case may be related to its anticancer properties, as described in phase III trials in various tumor types.