Lucilla Verna

Gabapentin in the treatment of hiccups in patients with advanced cancer: a 5-year experience.

Aim:To evaluate safety and efficacy of gabapentin in the treatment of severe chronic hiccups in patients with advanced cancer. Methods:Charts of all patients observed in the palliative care unit of a 4-bed hospital and at home by our Home Care Service were reviewed retrospectively.The presence of hiccups was routinely assessed. Patients with severe chronic hiccups were treated with gabapentin (300 mg t.i.d.). Doses of gabapentin were titrated based on the response to treatment.Gabapentin-related adverse effects were recorded. Results:Thirty-seven (3.9%) of 944 in-hospital patients and 6 (4.5%) of 134 patients observed at home presented severe chronic hiccups.We registered an improvement of hiccups, defined as complete resolution of hiccups, in 31 (83.8%) of 37 in-hospital patients and 4 (66.7%) of 6 patients observed at home.Four (10.8%) of the 37 in-hospital patients and 2 (33.3%) of the 6 patients observed at home experienced a reduction of hiccups.In 2 patients (5.4%), we registered a worsening of hiccups.Responses were observed in 32 patients (74.4%) with gabapentin at a dosage of 900 mg/d and in 9 patients (20.93%) at 1200 mg/d.In 2 patients (4.65%), grade 2 sleepiness was observed and in 10 patients (23.25%), grade 1 sleepiness was observed based on the Epworth Sleepiness Scale. Conclusion:The results of the study allow suggesting gabapentin at least as a promising drug in the treatment of severe chronic hiccups in advanced cancer patients.

The Supportive Care Task Force at the University of L’Aquila: 2-years experience

The Supportive Care Task Force (SCTF) was established within the Medical Oncology Department at the University of L’Aquila in May 2002. The missions of the SCTF were to allow systematic evaluation and treatment of symptoms, to warrant continuity of care in all phases of disease and to provide medical oncology residents with training in the treatment of symptoms. A medical oncologist, two senior residents in medical oncology and a registered nurse comprised the SCTF. A psychiatrist, two neurologists, a dietician, and two physiotherapists served as consultants or on a part-time basis. Four beds in two-bedded rooms inside the Medical Oncology Department were reserved to SCTF. A close integration with the physicians of the Medical Oncology Department was realised. The only criterion to admission was the presence of uncontrolled symptoms. Patients were evaluated and monitored with the visual analogue scale for pain and with the Edmonton Symptom Assessment Scale (ESAS). The Palliative Prognostic Score (PaP Score) was employed to assess the prognosis. Non-clinical needs were evaluated with the Need Evaluation Questionnaire (NEQ). Protocols for the treatment of common symptoms were available in written form for consultation by physicians, residents and nurses. From 1 May 2002 to 31 May 2004, we observed 208 patients: 111 women and 97 men. The median age was 64.7 (range 28–90) years. Fifty-four patients (25.9%) were admitted more than once, for a total of 285 admissions. One hundred ninety-nine admissions (69.5%) were for supportive care while 86 admissions (30.5%) were for supportive care and active treatment. The most frequent symptoms were asthenia and anorexia. We registered excellent results regarding the treatment of pain, nausea and dyspnea while psychological symptoms, anorexia and asthenia proved more difficult to treat.Two hundred twenty patients were discharged: 142 (49.8%) home; 76 (26.7%) to the Home Care Service and two (0.7%) to others units of the hospital. Sixty-five (22.8%) died in our unit.

Opioid switching from and to tapentadol extended release in cancer patients: conversion ratio with other opioids

Abstract Objectives: The aim of this exploratory study was to assess the conversion ratios between tapentadol and other opioids in patients requiring an opioid switching. Methods: A prospective study was carried out in a convenience sample of consecutive patients admitted to an acute palliative care unit and a home care unit for a period of 1 year. Patients who were switched from/to tapentadol were selected. The initial ratio between tapentadol and other opioids, expressed as oral morphine equivalents was 1:3.3. The subsequent doses were flexible and were changed to fit the patients’ needs. Pain intensity and distress score were recorded until opioid doses were stable. In all, 37 patients were examined; 24 and 13 patients were switched from and to tapentadol, respectively. Results: The most frequent sequences were tapentadol–morphine (18 patients) in one direction, and morphine–tapentadol (8 patients) in the other direction. In the sequence tapentadol–morphine and morphine–tapentadol, the mean final tapentadol–morphine ratios were 3.9:1 (SD 2.3), and 1:4.5 (SD 3.2), respectively, which did not differ significantly from the initial established conversion ratio. A minority of patients were switched from/to tapentadol to/from other opioids. Globally, the initial ratio did not change after switching took place. Conclusion: Data suggest that a conversion ratio between tapentadol and other opioids, expressed in oral morphine equivalents could be 1:3.3 in both direction, particularly in patients who are switched in conditions of equianalgesia. The limited number of patients prevents a definitive conclusion to be drawn, and data should be interpreted with caution, given the exploratory nature of the study and the question of the low number of patients should be addressed in future studies.

Low doses of transdermal buprenorphine in opioid-naive patients with cancer pain: a 4-week, nonrandomized, open-label, uncontrolled observational study.

OBJECTIVE The aim of this study was to evaluate the effect and tolerability of low doses of transdermal (TD) buprenorphine patches in opioid-naive patients with cancer pain. METHODS This was a nonrandomized, open-label, uncontrolled study in consecutive opioid-naive patients with advanced cancer and moderate pain. TD buprenorphine was initiated at a dose of 17.5 microg/h (0.4 mg/d), with patch changes every 3 days. Doses were then adjusted according to the clinical response. Pain intensity, opioid-related adverse effects, TD buprenorphine doses, and quality of life were monitored over 4 weeks. The time to dose stabilization and indexes of dose escalation were also calculated. RESULTS Thirty-nine consecutive patients completed all 4 weeks of the study. Low doses of TD buprenorphine were well tolerated and effective in these opioid-naive patients with cancer pain. Pain control was achieved within a mean of 1.5 days after the start of TD buprenorphine therapy. The mean TD buprenorphine dose was significantly increased from baseline beginning at 2 weeks after the start of therapy and had doubled by 4 weeks (P < 0.05). Pain intensity was significantly decreased from baseline beginning at 1 week and continuing through the remaining weekly evaluations (P < 0.05). The mean buprenorphine escalation index, calculated as a percentage and in milligrams, was 41.2% and 0.2 mg, respectively. Quality of life improved significantly over the study period (P = 0.007). There were no significant changes in opioid-related symptoms between weekly evaluations. CONCLUSION Observations from this study suggest that randomized, controlled, double-blind studies of TD buprenorphine 17.5 microg/h in opioid-naive patients with cancer pain may be warranted.

Assessment and treatment of symptoms among Italian medical oncologists

ObjectivesThis work was conducted to evaluate symptoms assessment and use of patient-tailored protocols in clinical practice among Italian medical oncologists.MethodsA questionnaire based on four topics (assessment of symptoms, assessment of a specific symptom, assessment of pain, use of patient-tailored protocols of treatment) was administered to 250 Italian medical oncologists.Results: Of these oncologists, 43.7% used multiple symptoms tools and 37.9% used symptom specific tools; 58.9% used some instrument to assess pain. More than a third of the respondents (35.5%) used patient-tailored protocols. No statistical differences were found regarding region of residency, availability of consultants in pain therapy and/or palliative care, colleagues with main interest on palliative care, and beds dedicated to palliative care. Statistically significant differences were found regarding the position (staff/resident) in three out four topics.ConclusionsAmong Italian medical oncologists, the instruments used for assessment of symptoms are poorly employed. Even when these instruments are used, patient-tailored protocols are rarely administered.

Integration between oncology and palliative care: does one size fit all?

ABSTRACT This is a letter to the editor with critical appraisal of some aspects about indicators of integration of oncology and palliative care programs analyzed by David Hui et al. in a recent paper published on Annals Of Oncology -Ann Oncol 2015; 26(9): 1953-1959.

Home care for cancer patients after an earthquake: the experience of the "L'Aquila per la Vita" Home Care Unit.

To the Editor: In recent years, several natural disasters have occurred around the world. Millions of people have found themselves without homes as a result, and this has posedmajor concerns for public health. In many cases, health care providers were unprepared to cope with these emergencies and to care for patients affected by chronic diseases. To our knowledge, there are no reports available on oncology home care after a catastrophe. The aim of this letter was to describe the experience of the ‘‘L’Aquila per la Vita’’ Home Care Unit (HCU) after the earthquake in L’Aquila. On April 6, 2009, an earthquake destroyed the city of L’Aquila, the capital of the Abruzzo region in central Italy. Of 70,000 inhabitants, 309 died and more than 1000 were injured. The mayor declared that many homes were completely destroyed, and the city hospital was evacuated, too. According to the environmental situation and contingent needs, the HCU tried to provide the best options available in three different phases: 1) nonabandonment, 2) continuity of care, and 3) return to normality.

Pain evaluation and management: a survey of Italian radiotherapists

GoalsThe objective of this study was to assess the knowledge possessed and the attitudes held by Italian radiotherapists regarding evaluation and treatment of pain.MethodsOne hundred and twenty-six radiotherapists completed a 16-item questionnaire that was specifically designed to investigate three main topics: the attention paid to pain, the use of analgesics, and pain in children. Chi-square or Fisher’s exact text was employed to evaluate differences based on position (staff/resident), age (<35/>35 years old), availability of consultants in pain therapy and/or palliative care, colleagues with main interest in palliative care among their own staff, and region of residence (north/center/south of Italy).ResultsOverall percentage of correct answers was 76.6% (range 34.9–94.4%). Correct answers by groups of items were: attention paid to pain 77.3%, use of analgesics 81.5%, and pain in children 63.7%.ConclusionResults of the survey demonstrate that knowledge and attitudes of Italian radiotherapists towards the approach to and treatment of pain can be considered satisfactory.

Pattern of symptoms and symptomatic treatment in adults and the aged population: a retrospective analysis of advanced cancer patients followed at home

Abstract Context Data regarding symptom burden and symptomatic drugs in palliative population in different classes of age are lacking. Objective The aim of this retrospective study was to assess the symptom burden, and the profile of symptomatic drugs in the last four weeks of life in adults and older cancer patients followed at home. Methods Charts of 412 patients were retrospectively analyzed by using a backward analysis. Patients were divided into three groups: adults (<65 years, A), old (65–74 years, O1), very old (75–84 years, O2), and the oldest (≥85 years, O3). Results At -4W Karnofsky status was significantly lower for older people (p = 0.03). No significant effect of age on the vector of symptoms was found (p = 0.07). A significant decrease in intensity of pain and nausea, and an increase in intensity of all other symptoms was found through the four weeks of the study (p = 0.00). No differences of drug pattern among the age categories were found. The use of symptomatic drugs decreased over time, except for opioids. Age statistically affected NSAID use, neuroleptic use, and antiemetics over time. Conclusion The burden of symptoms worsened in the last four weeks of life, except for pain and nausea, but did not differ among the age subgroups. The use of NSAIDs, neuroleptics, and antiemetics changed, while the frequency of opioid use was unchanged until death.

Knowledge and Attitudes of Young Italian Medical Oncologists Toward the Approach and Treatment of Pain: No Changes, Despite the Law

In 2001, Visentin et al. published the results from a single-center survey on basic knowledge and attitudes of physicians and nurses toward pain, conducted in an Italian hospital. Based on the percentage of correct answers (from 30% to 96%), they concluded that there were significant knowledge deficits and erroneous beliefs that might hamper treatment of the patient in pain and that these results would help in designing educational programs aimed at improving pain treatment [1]. In 2002, during the 4th Italian National Congress of Medical Oncology, we administered the same questionnaire to 100 residents in oncology. The median overall percentage of correct answers was 89%, which varied from 35% to 97% among the different items: 75.4% for items regarding the use of analgesics, 87.2% for items regarding attention to pain, and 73.3% for items regarding pain in children. In our opinion, these results indicated that the knowledge and attitudes about treatment of pain among residents in oncology might be considered adequate [2]. Educational programs on core competencies in the assessment and management of cancer pain have likely driven an improvement in the last years. Moreover, the Italian legislation now also protects patients’ rights by setting “measures to guarantee the access to palliative and pain treatments” (Law 38/ 2010) [3]. Nevertheless, we still observed barriers and limitations in pain-related knowledge and practice among the oncology community.