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SHORT CUTS

2 Nov, 11 | by Assistant Editor

Articles of interest in other scholarly journals

Click on the article headings to view abstracts

Antagonistic effects of ondansetron and tramadol? A randomised placebo and active drug controlled study.

Rauers NI, Stüber F, Lee EH, Musshoff F, Fimmers R, Barann M, Stamer UM.

This postoperative randomised, double-blinded study assessed if ondansetron and tramadol had opposing effects and if co-administration decreased their efficacy. It showed that using both drugs together did not increase tramadol use or emesis.

Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients.

Dev R, Parsons HA, Palla S, Palmer JL, Del Fabbro E, Bruera E.

In this retrospective study of 665 patients, the frequency of undiagnosed alcoholism among patients with advanced cancer and its relationship to alcoholism, smoking and use of illegal drugs was assessed. 598 patients had completed the Cut Down, Annoyed, Guilty, Eye Opener (CAGE) questionnaire. The frequency of CAGE-positive results was 17%, of which only 13% had been identified before their palliative care consultation. These patients were more likely to have a current and past history of smoking, and illegal recreational drug use. Pain and dyspnea were worse in patients who had a history of nicotine use. Both CAGE-positive patients and patients who had a history of tobacco use more frequently were receiving strong opioids at the time of their palliative care consultation.

The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: A qualitative study.

Harris D, Finlay I, Flowers S, Noble S.

The practice of relieving patient distress through sedative doses of anxiolytics or opioids in terminal haemorrhage was evaluated through Semi-structured interviews with 11 specialist nurses. This showed that anxiolytics and opioids rarely benefit the patient who is having a terminal haemorrhage as it is so rapid that patients died before it could be administered. Furthermore, it may remove nurses from giving patient care, as staying with and supporting the patient, as well as using dark-coloured towels to camouflage blood was reported to be of more practical use. The focus on administering medications was often to the detriment of these non-pharmacological approaches.

Unidirectional Cross-Activation of GRPR by MOR1D Uncouples Itch and Analgesia Induced by Opioids.

Liu XY, Liu ZC, Sun YG, Ross M, Kim S, Tsai FF, Li QF, Jeffry J, Kim JY, Loh HH, Chen ZF.

Spinal opioids can cause itch, which has previously been thought to result from pain inhibition. This study separates the sensation of itch from analgesia, demonstrating that morphine directly induces itch in a subset of spinal neurons by signalling through a heterodimer of opioid (μ-opioid receptor isoform 1D) and gastrin-releasing peptide receptors. In addition, blocking MOR1D-GRPR association attenuates itch but not analgesia. This study also evaluated the downstream effectors of GRPRs and suggests potential pharmacological targets.

Non-steroidal anti-inflammatory drugs and risk of pulmonary embolism.

Biere-Rafi S, Di Nisio M, Gerdes V, Porreca E, Souverein P, Boer A, Büller H, Kamphuisen P.

In a case-control study (of 4433 cases and 16,802 controls) using a Dutch registry the population based effect of non-steroidal anti-inflammatory drugs (NSAIDs) on pulmonary embolism (PE) was assessed. Current use of NSAIDs was associated with PE, with the overall risk for NSAIDs being highest in the first 30 days of use. Use of acetaminophen and tramadol also increased the risk of PE with a similar time trend. Although NSAIDs are associated with an increased risk of PE, this might be due to the underlying medical condition for which they are prescribed, as suggested by a similarly increased thrombotic risk in patients receiving paracetamol and tramadol.

Comparative clinical effects of hydromorphone and morphine: a meta-analysis.

Felden L, Walter C, Harder S, Treede RD, Kayser H, Drover D, Geisslinger G, Lötsch J.

In this meta-analysis of eight studies the analgesic effects of morphine and hydromorphone were compared. It suggested that hydromorphone (494 patients) provides slightly better (P=0.012) clinical analgesia than morphine (510 patients). The effect-size was small although the advantage of hydromorphone was more evident in studies of better quality. Nausea, vomiting and itching were similar. This suggests some advantage of hydromorphone over morphine for analgesia. The authors suggest that hydromorphone’s safety in renal failure or during acute analgesia titration, are based on limited evidence and require substantiation by further studies.

Methadone toxicity due to smoking cessation–a case report on the drug-drug interaction involving cytochrome P450 isoenzyme 1A2.

Wahawisan J, Kolluru S, Nguyen T, Molina C, Speake J.

To report the potential clinically significant pharmacokinetic interaction that may result from smoking cessation in patients on methadone maintenance therapy.

This case report describes a 46-year-old man with decreased respirations and altered mental status related to methadone toxicity, despite being on a stable dose of methadone for chronic back pain. These toxicities resolved by withholding and then reducing the methadone dose. It was subsequently noted that he had recently stopped smoking, which was thought to be the precipitating factor. The explanation for this effect is that tobacco smoke contains polycyclic aromatic hydrocarbons which induce the cytochrome P450 CYP1A2 enzymes which partly metabolise methadone and decreased smoking can lead to a reduction in methadone metabolism, resulting in higher serum concentrations

By Jason Boland, Consultant in Palliative Medicine, Barnsley Hospice, United Kingdom

Department of Health in England launches end of life survey

27 Oct, 11 | by Assistant Editor

A new survey commissioned by the Department of Health aims to gauge the quality of end of life care in England. The project, which is being administered by the Office for National Statistics (ONS) will involve sending a postal survey to 49,000 individuals who registered the death of a loved one between November 2010 and June 2011.

Questions will relate both to the quality of care that the loved one received and also the support available to the respondents themselves. The results of the survey will inform the DoH End of Life Care Strategy which aims to improve the care available to people dying from long-term illness.

The results of the survey should be made available in March 2012.

Read the 2008 End of Life Care Strategy here.

British GPs urged to “find their 1%”

25 Oct, 11 | by Assistant Editor

A new campaign by the Dying Matters Coalition is encouraging GPs to identify the 1% of their patients who are entering their last year of life.

The Find Your 1% project aims to promote discussion of end-of-life care in order to increase the number of people dying at home. A report released last year by the National End of Life Intelligence Network showed that whilst over 60% of people would prefer to die in their own home, only around 20% actually are.

A key goal of the campaign is to encourage people to think about where they would like to die, as well as to empower them to tell their carers and loved-ones where they would like to spend their final days.

In order to recognise individuals who may benefit from the scheme, GPs are urged to ask themselves the question “Would I be surprised if this person were to die in the next 12 months?” during routine consultations with patients.

However, accurately predicting someone’s life expectancy at any given age is generally very difficult (particularly if they haven’t been diagnosed with a serious illness) and some commentators, including Northumberland LMC secretary Dr Jane Lothian, have suggested that the ‘somewhat arbitrary’ selection of patients may be ethically unsound.

Find out more about the campaign here.

Increase in admissions to palliative care in Australian hospitals

21 Oct, 11 | by Assistant Editor

A new study by the Australian Institute of Health and Welfare (AIHW) shows that over the last decade the number of hospital admissions for palliative care services has increased by over 50%.

This news was well received by Palliative Care Australia (PCA), an organisation which promotes the provision of quality end of life care. Dr Yvonne Luxford, PCA Chief Executive said “This is a fantastic indicator that our hospital system is gaining an understanding of the need to refer people to palliative care. What we need to make sure, however, is that people are receiving high quality care, and one way to do this is by ensuring that education about palliative and end of life care is a standard provision for all health professionals.”

Maintaining quality of care is especially important in light of the study’s other main finding – that the average length of hospital stay for palliative care patients in Australia is 12.5 days – almost four times longer than the average for all admissions (3.2 days). With palliative care provision and utilisation on the rise, more funding may well be needed to keep care quality at a premium.

The study also showed that people with cancer are overwhelmingly referred to palliative care (69% of cancer patients in the study), but that only 21% of individuals suffering from heart failure and 20% from COPD were admitted to palliative care services, highlighting a discrepancy in the types of serious illness which are considered to benefit from palliation.

Read the full report here.

Access to palliative care in the US is improving but further work is needed.

14 Oct, 11 | by Assistant Editor

The US-based Center to Advance Palliative Care has issued a national ‘Report Card’ which upgrades the overall level of palliative care accessibility in the country to a B grade, up from C in 2008.

But whilst the number of hospitals with specialist palliative care units has increased significantly in recent years (more than doubling since 2000), there is still room for improvement, with Diane Meier, director of the Center, stating that “millions of seriously ill Americans still do not have access.”

As well as an overall national grade, the report marked states individually, with seven states (including Minnesota, Vermont and Washington) scoring an A – up from just three in 2008. Most states received a B grade, with only two – Delaware and Mississippi – given an F.

Read the full report and view the interactive map here.

WPCA Report Highlights Serious Shortcomings in International Palliative Care Provision

11 Oct, 11 | by Assistant Editor

A new report by the Worldwide Palliative Care Alliance shows that 32% of countries still have no known palliative care activity whatsoever.

The study, entitled “Mapping levels of palliative care development: A global update 2011”, compiled detailed information about the level of hospice and palliative care provision in every country worldwide. The results also showed that only 136 out of 234 countries (58%) had a dedicated hospice or palliative care service – up 9% since 2006 but still startlingly low.

The most improved region since the last report was Africa, largely due to the work of the African Palliative Care Association, who helped to build capacity and improve care provision in several countries, including Malawi, Tanzania and Zimbabwe. Some isolated services have also been established in the Middle East, providing limited care where before there was none.

Despite the small headway which has been made, however, the report raises serious concerns about the huge number of seriously ill people worldwide for whom palliative care is either highly inadequate or nonexistent. WPCA estimate that 100 million patients and caregivers would benefit from hospice and palliative care, but these figures show that only a fraction currently have access to it.

Read the report here.

A recent talk exploring current issues in palliative care research and practice.

10 Oct, 11 | by Assistant Editor

Dr Miriam Johnson, Senior Lecturer in Palliative Medicine at Hull York Medical School, explains why she believes that patients with non-malignant conditions are often excluded from access to effective palliative care. She also outlines current understanding of the best way to palliate breathlessness and to successfully plan for end of life care amongst patients with non-malignant conditions. Watch her talk at the Royal Society of Medicine here.

Cloak and Needles

6 Oct, 11 | by Assistant Editor

I can see:  a frozen nose and few veins in the same place.

The bird without a beak outside of the window flutters and goes away.

I wish that outside of the window things will happen without a bird, not now…

His existential pain is growing like tree amidst baroque music.

This is new for him.

This is the room where the lions will come to eat his liver full of inflammable cells.

Now he knows how stiff the bone is upon the flesh.

Here things get in and out, in and out with no names or desire.

We can’t have eyes for this silence around his head made of memories.

We can’t even go after the marriage of the sunset.

Perhaps if I touch his flesh right now, everything will be like inside of a lamp: infinite, no more pain…

No one has ever opened the door at night to see the stones awaken by his disease.

You may think too much, you still wonder how to cure, how to comfort, but he knows: he already knows more…

He couldn’t find the fallen principles made of other lives to surprise the obstacles, the tact, the hand, the living.

He is the appetite of a simple chest fabricating particles and blood.

His lymphoma of darkness it’s now like a forest each time he breathes.

If I go inside I will never be back again…

by Rafael Bloise

New resource aims to advance measurement in palliative care

29 Jun, 11 | by BMJ

Patients are set to benefit from the new Palliative Care Outcome Scale (POS), a tool developed to assist clinicians, researchers and other healthcare workers in measuring physical symptoms; psychological, emotional and spiritual needs; and provision of information and support at the end of life.

Developed by Professor Irene J Higginson, POS is a free resource available in 12 languages.

More information on POS is available here.

News and updates from palliativedrugs.com

27 Jun, 11 | by BMJ

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Safety Updates

McKinley T34 extension sets: UK Medicines and Healthcare products Regulatory Agency (MHRA) issue recall

All T34 syringe pump extension sets manufactured by CME (McKinley Medical UK) before 1 January 2011 have been recalled due to the potential for leakage at the female luer syringe connector. Product codes affected are: 100-172S, 100-170S, 100-172SLL, 100-172SB, 100-172SC. Returns and replacement stock can be obtained by contacting Paul Fletcher (McKinley Medical UK, 01253 894646, email: pfletcher@cme-mckinley.co.uk). The manufacturer states that other syringe sets can be used in the interim (ensuring local guidelines and practice are adhered to). For more information click here.

European Medicines Agency (EMEA) complete review of potential interaction between alcohol and opioid modified-release mechanisms

This review was undertaken following reports of the risk of alcohol dissolving the modified-release coating leading to a more rapid release of drug than intended. The conclusions are that for the majority of modified-release products the risk is minor but that the SPC and PIL across the whole class should be updated with consistent warnings that the concomitant use of alcohol with opioids may enhance the pharmacodynamic effect and should be avoided. However, for modified-release drugs which use a ‘polymethacrylate-triethylcitrate controlled release system’, the EMEA concluded that the marketing authorizations should be suspended until formulations which are more stable in alcohol are produced. The affected product appears to be Ethirfin (morphine sulphate, prolonged-release capsules, 20, 60, 120 and 200mg) previously available in Denmark. For more information click here.

Lenalidomide: UK Medicines and Healthcare products Regulatory Agency (MHRA) safety warning

Lenalidomide (Revlimid, Celgene) is authorised in combination with dexamethasone for multiple myeloma in patients who have received at least one previous treatment. However, evidence from clinical trials and case reports suggest that lenalidomide further increases the already elevated risk of venous and arterial thrombo-embolism in these patients, including myocardial infarction and cerebrovascular accident. The SPC has been amended accordingly. For more information click here.

US Food and Drug Administration (FDA) limits the amount of acetaminophen (paracetamol) to 325mg per dosage unit

The US FDA has asked manufacturers to reformulate prescription products containing acetaminophen (paracetamol) so that a single dosage unit contains a maximum of 325mg acetaminophen. This includes combination products of acetaminophen and opioids. Dosage recommendations will not change and the maximum dose remains 4g/day. For more information click here.

US Food and Drug Admnistration (FDA) announces Risk Evaluation and Mitigation Strategy (REMS) for modified-release opioids

The US FDA has published its REMS for all modified-release opioid drugs which aims to reduce their inappropriate prescribing, misuse, and abuse. Manufacturers are required to develop an educational program for prescribers and patients. For more information click here.

Prepared by Sarah Charlesworth and Andrew Wilcock

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