Miguel Ángel Benítez-Rosario

Morphine-Methadone Opioid Rotation in Cancer Patients: Analysis of Dose Ratio Predicting Factors

The dose ratio that is effective when switching opioid therapy from morphine to methadone in cancer patients varies widely. There are no conclusive data explaining the source of this variability. We analyzed 54 cancer patients undergoing opioid rotation to clarify those factors that influenced the morphine/methadone dose ratio (MMEDR) at Day 10 after the switch. Reasons for switching were uncontrolled pain (10 patients) or side effects (with or without pain, 44 patients). Initial MMEDR was 5:1 or 10:1 (82% or 18% of patients, respectively). Multivariate regression analysis was used to identify the demographic, cancer-related, and treatment-related variables that were potential predictors of MMEDR. Median previous morphine dose for the entire sample was 220 mg/day (range: 30-1000 mg/day). The stable MMEDR median was 5:1 (range: 2:1-15:1). In the univariate analysis, reasons for opioid rotation, age, and previous morphine doses were associated with MMEDR. Multiple linear regression analysis showed that only the reason for switching (pain vs. side effects; P<0.001) and previous morphine doses (lower vs. upper to 300 mg/day; P<0.001) were associated with MMEDR. From this analysis, the MMEDRs for patients rotated for side effects at 300 mg/day or more or less than 300 mg/day of morphine were 9.1:1 or 5.6:1, respectively, and the MMEDRs for those switched for pain at 300 mg/day or more or less than 300 mg/day of morphine were 4.9:1 or 3:1, respectively. Both the reasons for opioid rotation and previous morphine doses are predictive factors and should be used to select the MMEDR more accurately.

A Strategy for Conversion From Subcutaneous to Oral Ketamine in Cancer Pain Patients: Effect of a 1:1 Ratio

CONTEXT No consensus exists about the most appropriate dose ratio for conversion from parenteral to oral ketamine. OBJECTIVES To confirm that a 1:1 dose ratio is suitable for converting subcutaneous (s.c.) to oral ketamine in cancer patients. METHODS Patients with opioid poorly responsive cancer pain, who responded to 0.4, 0.6, or 0.8 mg s.c. ketamine bolus, were treated with 0.1, 0.15, or 0.2mg/kg/h ketamine infusion, respectively. Switching to the oral route, by applying a 1:1 dose ratio, was carried out in patients who experienced adequate pain relief and continued to need ketamine as a coanalgesic. Pain, somnolence, feelings of insobriety, confusion, and cardiovascular parameters were assessed throughout the process. RESULTS Twenty-nine patients were enrolled in the study. Ketamine infusion decreased pain intensity from severe to no pain or slight pain in 23 of 29 and six of 29 patients, respectively. The median of s.c. ketamine doses was 0.2mg/kg/h (range 0.1-0.5). After oral switching, 27 of 29 patients remained as successfully controlled as when receiving s.c. ketamine. The other two patients needed a slight dose ratio readjustment, to 1:1.3 and 1:1.5, to maintain pain control. The median of oral ketamine doses was 300 mg/day (interquartile range 240-382.5). Seven of 29 patients receiving s.c. ketamine developed moderate and transitory side effects, such as feelings of insobriety and somnolence. No side effects were present while receiving oral ketamine. No significant changes were observed in cardiovascular parameters. CONCLUSION A 1:1 dose ratio for conversion from s.c. to oral ketamine is safe and effective in cancer pain patients.

Quality of Care in Palliative Sedation: Audit and Compliance Monitoring of a Clinical Protocol

CONTEXT The European Association for Palliative Care and the U.S. National Hospice and Palliative Care Organization have published statements that recommend an audit of palliative sedation practices. OBJECTIVES The aim was to assess the feasibility of a quality care project in palliative sedation. METHODS We carried out an audit of adherence to a guideline regarding palliative sedation, undertaken as a yearly assessment during two years, of a sample of patient charts. With an audit tool, the charts were evaluated as to the presence of the ethical sedation checklist, information that justified palliative sedation, patient and/or family agreement, and the appropriateness of treatment in concordance with the clinical protocol. An educational program and result feedback meetings were used as the implementation strategy. RESULTS Roughly 25% of the medical charts of patients who died in the palliative care unit were evaluated, 94 in 2007 and 110 in 2008. In 2007 and 2008, 63% and 57% of the patients, respectively, whose median age was 65 years, were sedated, with a median length of two days. The main reason for sedation was agitation concomitant with respiratory failure in roughly 60% and 75% of the cases in 2007 and 2008, respectively. Agreement of the patient/family about sedation was collected from 100% of the cases. The concordance of procedures with the sedation guideline was 100% in both years. CONCLUSION Our quality-of-care strategy was shown to obtain a higher level of compliance with the palliative sedation guideline for at least two years.

Functional status and mortality in community-dwelling older people.

To the Editor: Functional status has been identified as an independent risk factor for poor results in rehabilitation programs, longer hospital stays, pneumonia severity, postsurgical morbidity, and mortality among institutionalized older people.1,2 In this study we examined whether functional status is a reliable predictor of short-term overall mortality in community-dwelling older people. A prospective 4-year follow-up study was performed in older people living in a rural community of Tenerife (Canary Islands, Spain). All patients age 65 and older admitted to the Primary Care Center during the recruitment year were eligible for the study. All subjects underwent a comprehensive geriatric assessment, which included information about variables related to health status, cognitive functions and depression, family status, and support networks. The functional status was assessed according to the Katz activities of daily living (ADL) scale.3 It allows ranking the patient in one of seven categories, from A to G, where A indicates the most-independent score and G the most-dependent score. All statistical analysis was performed with respect to the baseline assessment. Every subject was followed up until either death or the end of the study. An initial bivariate Pearson’s chi-square was performed to assess the association with death of the variables derived from the geriatric assessment. Then Kaplan-Meier survival curves were constructed and compared with the log-rank test. Lastly, Cox proportional hazard models were constructed to detect the effect on survival of different covariables, such as ADL impairment, age group, health status, specific illnesses, cognitive function, psychiatric disorders, social/family situation, and its interactions. Statistical significance was set at P .05, and relative risk of death for each factor group was estimated at 95% confidence intervals. During the recruitment year, 189 patients age 65 and older (76 7 years; mean standard deviation, with no differences per gender) were admitted to the study. Thirtyone subjects died during the study. In the bivariate analysis, the factors associated with mortality were age, heart disease, cognitive decline, and functional status (P .001). The Kaplan-Meier survival curves showed that 4-year survival rate was inversely and significantly associated (P .001) with the impairment in one or more ADLs (Figure 1). In the multivariate analysis, the association between survival and functional status proved to be independent of the presence of heart disease, cognitive deficits, absence of relative’s support, and other social-structure variables. The relative death risk associated with an increasing impairment in ADLs (from independence to dependence on one or more ADLs), adjusted for the variables of illness, was 6.5 (95% CI 5.3–7.2; P .001). After adjusting the Cox model for age in 5-year intervals, the interaction age–ADL score was a predictive factor for short-term mortality. Moreover, death risk increased in each age group when the ADL score increased (Table 1). Lastly, the interaction between age, as a continuous variable, and an increasing ADL score (dependence on one or more than one daily activity) was a predictive factor for death, with relative risks of 1.02 (95% CI 1.004–1.03; P .037) and 1.03 (95% CI 1.02–1.04; P .001), respectively. The present study shows that, independent of age and health condition, functional status, assessed through the Katz ADL scale, is a predictive factor for short-term mortality in noninstitutionalized older people. This is especially noticeable for more functionally dependent subjects. Our results are in line with the findings by Ostbye et al.,4 who reported a significantly greater death rate in dependent older people than in independent ones. Using mortality predictors based on functional ability, we can develop methods that can help us improve health care and the process of decision making in clinical practice, as has been previously suggested1,4 for hospitalized and nonhospitalized patients. Figure 1. Kaplan-Meier survival curves in non-institutionalized older people. A independent subjects; A subjects dependent on one or more activities of daily living according to the Katz scale. A vs. A (P .001; log-rank test)

El extracto de Ginkgo biloba no evita el deterioro cognitivo en las personas mayores

Objetivo Valorar si el Ginkgo biloba (GB) previene el deterioro cognitivo global, o de algunas funciones intelectuales, en personas mayores. Valorar si el posible beneficio esta relacionado con la edad o el APO E4. Diseno Ensayo clinico aleatorizado, doble ciego, frente a placebo, con un seguimiento de al menos 6 anos. Emplazamiento Seis departamentos universitarios de neurologia de EE.UU. Poblacion de estudio Consistio en 3.027 personas de 70 o mas anos que no presentaron ninguno de los criterios de exclusion: enfermedad debilitante con expectativas vitales menores a 5 anos, demencia, enfermedad de Parkinson, tratamiento con warfarina, anticolinesterasicos, vitamina E, L-dopa o farmacos con actividad anticolinergica como antidepresivos o neurolepticos, alteraciones hematicas, tiroideas o hepaticas, antecedentes de hemorragia, o alergia al GB. Un total de 2.711 personas completaron una o mas evaluaciones neuropsicologicas; 1.909 completaron 4 evaluaciones. Intervencion Se aleatorizaron 1.527 personas al grupo placebo y 1.545 al grupo de tratamiento con 120 mg de GB cada 12 horas. El 54% eran varones. Medicion del resultado Variaciones en tests neuropsicologicos globales, realizados semestral o anualmente: Mini Mental State Examination (MMSE), Alzheimers Disease Assessment Scale-cognitive subscale (ADAS-cog), Telephone Interview for Cognitive Status. Variaciones en la memoria, atencion, habilidades visuo-espaciales o funciones ejecutivas evaluadas mediante: California Verbal Learning Test, Rey Osterrieth Figure Test, WAIS-R, Boston Naming Test, Trail Making Test. Las puntuaciones fueron transformadas en valores z (transformacion logaritmica de la medias de las puntuaciones) para ser analizadas. Resultados principales La edad media de las personas incluidas fue 79 anos (rango 72-96). No se objetivaron durante el seguimiento cambios entre el grupo control y el de tratamiento con GB en las puntuaciones en el MMSE (p = 0,71) ni en el ADAS-cog (p = 0,97). Tampoco se observaron variaciones en las puntaciones de los tests de memoria (0,041; intervalo de confianza [IC]95%: 0,032–0,050 frente a 0,043; IC95%: 0,034–0,051), atencion (0,048; IC95%: 0,041–0,0540 frente a 0,043; IC95%: 0,037–0,050), habilidades visuo-espaciales (0,118; IC95%: 0,108–0,1280 frente a 0,107; IC95%: 0,097–0,117), lenguaje (0,041; IC95%: 0,033–0,0480 frente a 0,045; IC95%: 0,037–0,054) y funciones ejecutivas (0,089; IC95%: 0,082–0,0960 frente a 0,092; IC95%: 0,086–0,099). La ausencia de eficacia del tratamiento no se modifico por la edad, el sexo, el nivel de educacion, la presencia del APO E4 o el deterioro cognitivo leve presente al inicio del estudio. No hubo diferencias en el porcentaje de ictus, cardiopatia isquemica, sangrados mayores y mortalidad, ni en otros efectos adversos entre los grupos. Conclusion El tratamiento con 240 mg/d de GB no previene el deterioro de las funciones intelectuales en las personas mayores.

Las voluntades anticipadas mejoran los cuidados de las personas mayores al final de la vida

Objetivo Evaluar si una actividad para la promocion de realizar voluntades anticipadas influye en la atencion a las personas mayores al final de la vida. Diseno Ensayo clinico aleatorizado, de 6 meses de seguimiento. Emplazamiento Un hospital universitario de Melbourne, Australia. Poblacion de estudio Trescientas nueve personas de 80 anos o mas que estaban ingresadas en el hospital. Fueron excluidos pacientes con expectativas clinicas de alta o fallecimiento antes de que se pudiera realizar la intervencion, que dispusiesen de voluntades anticipadas, y los no competentes. Intervencion Tras seleccion al azar, 125 de 154 y 154 de 155 personas fueron asignadas al grupo intervencion y control, respectivamente. El grupo intervencion recibio informacion y apoyo, por personal especializado no medico, para establecer sus voluntades anticipadas sobre los cuidados que deseaban recibir al final de sus vidas. El grupo control no recibio ninguna actividad de fomento para la realizacion de las voluntades anticipadas. Medicion del resultado Grado de cumplimiento de las voluntades anticipadas en los ultimos dias de los pacientes que fallecieron. Grado de satisfaccion y niveles de estres-ansiedad de los familiares con los cuidados recibidos por las personas al final de su vida, determinado por la escala de impacto de eventos vitales y la escala hospitalaria de ansiedad y depresion. Resultados principales El 86% de las personas del grupo intervencion expreso sus voluntades anticipadas; solo el 56% lo realizo por escrito. De los que expresaron voluntades anticipadas, el 49% no deseaba reanimacion cardiopulmonar, el 17,6% dejaba la decision al respecto al medico o familiar, y el 28,1% deseaba la reanimacion si el resultado pudiera ser bueno. Respecto al mantenimiento de los tratamientos para prolongar la vida, el 36,1% de los anteriores dijo que no, y el 23,1% traspasaba la decision al medico o familiar. Se produjeron 56 exitus (29 y 27 grupo intervencion y control, respectivamente) en los 6 meses de seguimiento. En el 86% y en el 30% de las personas que murieron del grupo de intervencion y control, respectivamente (p Conclusiones La promocion para establecer voluntades anticipadas favorece que estas se realicen, sean conocidas y tenidas en cuenta en los cuidados al final de la vida de la personas mayores. Ello conlleva, ademas, mayor satisfaccion de los familiares con la atencion.

La terapia ocupacional mejora la recuperación de las funciones básicas de la vida diaria en pacientes que han tenido un accidente cerebrovascular: datos de un metaanálisis☆

Objetivo Evaluar si la terapia ocupacional mejora la funcion en las actividades basicas de la vida diaria en pacientes que han tenido un accidente cerebrovascular. Fuente de datos Se seleccionaron estudios publicados entre 1945 y marzo de 2007 citados en MEDLINE, Embase, CINAHL, PsycLIT, AMED, Wilson Social Sciences Abstract, Science Citation Index, Arts and Humanities Citation Index, Dissertations Abstract register, Occupational Therapy Research index y Cochrane Base. Seleccion de estudios Ensayos clinicos que evaluaron la eficacia de la terapia ocupacional, realizada por un especialista en la disciplina, en las actividades basicas de la vida diaria. La heterogeneidad estadistica de los estudios fue analizada mediante la χ2 y la l2. Se incluyeron 9 ensayos clinicos en el estudio de 14.593 publicaciones encontradas. Extraccion de datos Los datos fueron extraidos por 2 revisores, y analizados mediante la intencion de tratar. Se recogieron datos sobre fallecimientos, institucionalizacion, situacion afectiva y calidad de vida de los pacientes y cuidadores, grado de independencia en las actividades basicas de la vida diaria, y satisfaccion con la intervencion. Los datos fueron analizados con el modelo de efecto fijado de Peto. Resultados principales La revision incluyo los datos de 1.258 pacientes. El rango de edad fue de 55-87 anos, con una proporcion de varones que vario entre el 19 y el 60% segun los estudios. La diferencia media estandarizada para todos los estudios en un indice de independencia en las actividades basicas de la vida diaria fue de 0,18 (intervalo de confianza [IC] del 95%, 0,04-0,32) con una heterogeneidad no significativa (p = 0,3), que es equivalente a un punto de diferencia en el indice de 20 puntos de Barthel. La posibilidad de un mal resultado, muerte o deterioro de la funcion fue menor en los pacientes sometidos a terapia ocupacional (odds ratio = 0,67, IC del 95%, 0,51-0,87) con una heterogeneidad no significativa (p = 0,28). El numero de pacientes que era necesario tratar para obtener un mal resultado fue de 11 (IC del 95%, 7-30). No hubo diferencias significativas en el beneficio sobre el estado de animo de los pacientes y familiares. Conclusiones La terapia ocupacional en pacientes afectados por un accidente cerebrovascular podria aportar efectos beneficiosos en la mejora o la reduccion del deterioro en la capacidad para la realizacion de las actividades basicas de la vida diaria.