Articles of interest in other scholarly journals
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Murtagh FE, Cohen LM, Germain MJ.
As people are living longer, the number of patients with end-stage renal failure will increase and increasing numbers of patients who have a 6-month survival are starting dialysis. Furthermore, the rate of dialysis withdrawal has increased. Dialysis has its’ own risks and patients should be informed of the complex and challenging dialysis decisions. For a carefully selected group of patients, another option is not to dialyse and optimise medical and symptom management. This option would be based on clinician’s recommendations along with patient choice and family input. Age, co-morbidities and the patients’ functional capacity should be assessed as these are likely to indicate the patients’ survival and potential benefit from dialysis.
Potentiation of μ-opioid receptor-mediated signaling by ketamine.
Gupta A, Devi LA, Gomes I.
In this study the molecular mechanisms by which ketamine enhances opioid analgesia and prevents hyperalgesia are assessed. It was found that ketamine, via a non-NMDA receptor action, rapidly enhanced opioid-induced extracellular signal-regulated kinase (ERK) phosphorylation and increased resensitisation of opioid-mediated ERK signalling. This study indicates that ketamine might enhance opioid analgesia by increasing the effectiveness of opioid signalling.
Arroyo-Novoa CM, Figueroa-Ramos MI, Miaskowski C, Padilla G, Paul SM, Rodríguez-Ortiz P, Stotts NA, Puntillo KA.
this randomized, cross-over study investigated differences in pain and adverse effects when 11 male patients received either intravenous 0.1 mg/kg morphine or 0.05 mg/kg morphine and 0.25 mg/kg ketamine before an open wound care procedure. Although the pain intensity during wound care was less with the addition of ketamine, over 90% of patients had altered sensations, hallucinations, blurred vision and had an increased diastolic blood pressure. The authors suggest that further research is needed to determine the optimal dose of ketamine and if a benzodiazepine would alleviate the side effects of ketamine.
Nabal M, Librada S, Redondo MJ, Pigni A, Brunelli C, Caraceni A.
This systematic review evaluated the evidence for the efficacy of adding non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol to strong opioids for the treatment of cancer pain. Five of the seven eligible studies showed an additive effect of NSAIDs when combined with opioids, by either improving analgesia or reducing the opioid dose. Paracetamol was only marginally effective in one study. Toxicities could not be evaluated due to the small number of patients and the short treatment duration. There is some clinical evidence that the addition of NSAIDs to strong opioids can improve analgesia or reduce opioid dose requirement, but insufficient evidence to support the use of paracetamol in combination with strong opioids.
Update on the role of palliative oxygen.
Davidson PM, Johnson MJ.
This article reviews the evidence for the efficacy and appropriateness of palliative oxygen in the management of malignant and non-malignant breathlessness. It takes into account the costs, treatment burden and potential dangers. Although, the benefits of long-term oxygen for chronic obstructive pulmonary disease patients with severe hypoxaemic are proven, oxygen is no better than medical air for the relief of refractory breathlessness in patients with mild or absent hypoxaemia. The authors suggest that palliative oxygen should only follow detailed assessment of pathogenesis and reversibility of symptoms. Use of a fan, exercise and psychological support for patients and carers, should be considered before oxygen therapy. If palliative oxygen is considered for patients with transient or mild hypoxaemia, a therapeutic trial should be conducted with clinical review after three days to assess the overall clinical benefit.
The care of the very old in the last three days of life.
Rashidi NM, Zordan RD, Flynn E, Philip JA.
This retrospective review of medical records evaluated the symptoms and medications in the last three days of life for patients over 80 years old, dying in a palliative care unit. One hundred five Patients aged 80 years and older were compared with 100 aged 50 to 70 years. Patients over 80 had a shorter length of stay, had less parenteral opioids and benzodiazepines, but had similar symptom profiles. The authors highlight the need for prospective studies and suggest that this information should be used for service planning to improve care.
Meagher DJ, Leonard M, Donnelly S, Conroy M, Adamis D, Trzepacz PT.
100 patients receiving palliative care with delirium (DSM-IV) were assessed throughout their delirium episodes using three delirium rating scales evaluating severity, motor subtype and aetiology. Motor subtypes were hypoactive (28%), mixed (18%), hyperactive (10%) and variable throughout the episode (38%). 6% had no subtype. Those with a mixed subtype were most severely affected. Benzodiazepine and antipsychotics were used more frequently in hyperactive patients. Patients with sustained hypoactive delirium had the poorest prognosis and were significantly more likely to die within one month.
Ishihara M, Ikesue H, Matsunaga H, Suemaru K, Kitaichi K, Suetsugu K, Oishi R, Sendo T, Araki H, Itoh Y; The Japanese Study Group for the Relief of Opioid-induced Gastrointestinal Dysfunction (J-RIGID).
This multi-centre retrospective study investigated the effectiveness of prophylactic laxatives and antiemetics on the incidence of gastrointestinal toxicities in cancer patients who received opioids. Over 600 eligible hospitalised patients with cancer pain who received oral opioids for the first time were enrolled. The incidence of opioid-induced constipation was lower in patients receiving prophylactic laxatives, however, the incidence of nausea or vomiting was similar whether or not patients received prophylactic dopamine D2 blockers.
By Jason Boland, Consultant in Palliative Medicine, Barnsley Hospice, United Kingdom