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Aim: To evaluate the characteristics of patients with advanced cancer who die in an acute palliative care unit (APCU), and the risk factors for death in APCU., Methods: Adult consecutive patients with advanced cancer admitted to the APCU in a period of 13 months were prospectively assessed. At APCU admission, epidemiologic data, characteristics of admission, cachexia, being on-off anticancer treatment, and Edmonton Symptom Assessment System (ESAS) and MDAS (Memorial Delirium Assessment Scale) were assessed. Patients who died in APCU were extrapolated from the entire sample. A similar random sample of patients who were discharged alive in the same study period, matched for age and gender, was selected for comparison., Results: Fifty-four patients (12%) died in APCU. Statistical differences between died and discharged patients were found in MDAS (p =  < 0.0005), admission for cognitive/clinical decline (p =  < 0.0005), referral from specialistic home palliative care (p < 0.0005), cachexia (p = 0.018), being off cancer treatment (p =  < 0.0005), and symptom burden (total ESAS) (p = 0.002). At the multivariate analysis, independent factors associated with dying in APCU were MDAS (p = 0.006), referral from specialistic home palliative care (p = 0.025), being off cancer treatment (p = 0.002), pain and dyspnea intensity (< 0.05 and p = 0.038, respectively), and total ESAS (p = 0.025)., Conclusion: Mortality risk in APCU is associated with home palliative care referral, high symptom burden, and being off-cancer treatment. More proactive and timely end-of-life care is needed for these patients., Competing Interests: Declarations: All authors have approved the submitted version (and any substantially modified version that involves the author’s contribution to the study) and have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Competing interests: The authors declare no competing interests ., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aim: The aim of this study was to assess the Personalized Insomnia Intensity Goal (PIIG), the achievement of Personalized Goal Response (PGR), and Patient Global Impression (PGI) after a comprehensive symptom management., Patients and Methods: Advanced cancer patients admitted to palliative care units rated pain and symptoms intensity and their PIIG by using the Edmonton Symptom Assessment Score (ESAS) (T0). In patients with significant levels of insomnia, the achievement of target expected (PIIG) was measured (patient goal response, PIGR), as well the patient global impression (PGI), by the minimal clinically important difference (MCID), after a comprehensive symptom management (T7)., Results: Three hundred ninety-seven patients with a level of insomnia of ≥ 3 on ESAS were analyzed in this study. The mean values of PIIG at T0 and T7 were 1.2 (SD 1.5) and 0.9 (SD 1.4), respectively. Most patients (n = 406, 89.8%) indicated a PIIG of ≤ 3 as a target at T0. Such target was significantly lower at T7 (p = < 0.0005). PGI, expressed as MCID, was perceived with a mean decrease in insomnia intensity of - 2.3. In a minority of patients (n = 26; 5.8%) insomnia worsened, with a MCID of 0.50 (SD 2.8). Higher insomnia intensity at T0 and lower insomnia intensity at T7 were independently related to PGI. PIGR was achieved in 87.9% of patients. PIGR was associated with PIIG at T0, and inversely associated to insomnia intensity at T0 and T7, and PIIG at T7., Conclusion: PGIR and PGI seem to be relevant for evaluating the effects of a comprehensive management of insomnia, suggesting therapeutic decisions according to PIIG. Some factors influencing the individual target and clinical response have been detected.

Aim: The aim of this study was to investigate the relationship between delirium and symptom expression in patients with advanced cancer admitted to an acute supportive/palliative care unit (ASPCU)., Methods: A consecutive sample of patients with advanced cancer who were admitted to an ASPCU was prospectively assessed for a period of 10 months. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS (Memorial Delirium Assessment Scale) were measured at admission (T0) and after 7 days of palliative care (T7)., Results: Two hundred forty-six patients had complete data regarding MDAS measurements, at either T0 and T7. Of these, 75 (30.5%) and 63 patients (25.6%) had delirium at T0 and after a week of palliative care (T7), with a decrease in the frequency of delirium of 4.9% (from 30.5% to 25.6%); that means that 16% of patients with delirium improved their cognitive status after initiation of palliative care. Intensities of pain, depression, poor well-being, and global ESAS were significantly higher in patients with delirium. Patients who did not have delirium at T0 but developed delirium during admission after 1 week of palliative care had a higher level of symptom expression for pain, weakness, nausea, anxiety, dyspnea, appetite, and consequently global ESAS. Patients who did not develop delirium at any time had a relevant decrease in intensity of all ESAS items after 1 week of palliative care. The decrease of symptom intensity was significant for pain, insomnia, appetite, poor well-being, and global ESAS in patients with delirium either at T0 and T7, although these differences were less relevant than those observed in patients without delirium. In patients with delirium at T0 who improved their cognitive function at T7 (no delirium), significant changes were found in most ESAS items., Conclusion: Symptom expression is amplified in patients with delirium, whereas patients without delirium may be more responsive to palliative treatments with a significant decrease in intensity of ESAS items., Implications for Practice: Symptom expression is amplified in patients with cancer who have delirium, whereas patients without delirium may be more responsive to palliative treatments with a significant decrease in symptom intensity., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2018.)

Aim: The aim of this study was to assess the factors which influence the care pathway after discharge from an acute palliative supportive care unit (APSCU)., Methods: Patients' demographics, indications for admission, kind of admission, the presence of a caregiver, awareness of prognosis, data on anticancer treatments in the last 30 days, ongoing treatment (on/off or uncertain), the previous care setting, analgesic consumption, and duration of admission were recorded. The Edmonton Symptom Assessment Scale (ESAS) at admission and at time of discharge (or the day before death), CAGE (cut down, annoy, guilt, eye-opener), and the Memorial Delirium Assessment Scale (MDAS), were used. At time of discharge, the subsequent referral to other care settings (death, home, home care, hospice, oncology), and the pathway of oncologic treatment were reconsidered (on/off, uncertain)., Results: A total of 314 consecutive cancer patients admitted to the APSCU were surveyed. Factors independently associated with on-therapy were the lack of a caregiver, home discharge, and short hospital admission, in comparison with off-treatment, and less admission for other symptoms, shorter hospital admission, discharge at home, and better well-being, when compared with "uncertain." Similarly, many factors were associated with discharge setting, but the only factor independently associated with discharge home was being "on-therapy.", Conclusions: The finding of this study is consistent with an appropriate selection of patients after being discharged by an APSCU, that works as a bridge between active treatments and supportive/palliative care, according the concept of early and simultaneous care.

Background: The clinical response after comprehensive symptom management is difficult to determine in terms of a clinically important difference. Moreover, therapies should try to reach the threshold perceived by the individual patient for the determination of a favorable response to a treatment., Measures: The Edmonton Symptom Assessment Score (ESAS) was measured at admission (T0), and seven days after starting palliative care (T7). Patient Global Impression and Goal Response after one week of palliative care and its relation with the Personalized Dyspnea Goal were measured at T7., Intervention: Patients admitted to palliative care units underwent a comprehensive symptom assessment by a specialist palliative care team. At T0, patients were asked about their Personalized Dyspnea Intensity Goal on ESAS. One week later (T7), after a comprehensive palliative care treatment, Personalized Dyspnea Intensity Goals were measured again. Patients were considered to have achieved a Patient Dyspnea Goal Response if dyspnea intensity (measured at T7) was equal or less than their expected Personalized Dyspnea Intensity Goal. At the same interval (T7), Patient Global Impression (improvement or deterioration) was measured., Outcomes: 279 patients were analyzed in this study. The mean Personalized Dyspnea Intensity Goal at T0 and T7 were 0.97 (SD 1.3), and 0.71 (SD 2.1), respectively. 263 patients (94.2%) indicated a Personalized Dyspnea Intensity Goal of ≤3 as a target at T0. Patients perceived a bit better, a better improvement, and a much better improvement with a mean decrease in dyspnea intensity of -2.1, -3.5, and -4.3 points on the dyspnea intensity scale, respectively. In 60 patients (21.5%), dyspnea intensity did not change, and in 4.7%, dyspnea intensity worsened. Patients perceived a Minimal Clinically Important Difference (little worse) with a mean increase in dyspnea intensity of 0.10, and they perceived a worse with a mean increase of 1.7 points. Higher dyspnea intensity at T0 and lower dyspnea intensity at T7 were independently related to Patient Global Impression. At T7, 93 (33.3%) patients achieved their Personalized Goal Response, based on Personalized Dyspnea Intensity. Patient Dyspnea Goal Response was associated with Memorial Delirium Assessment Scale score and Personalized Dyspnea Intensity Goal at T0, and inversely associated with dyspnea intensity at T0 and T7, and lower Karnofsky level. For Patient Dyspnea Goal Response, no significant differences among categories of dyspnea intensity were found (P>0.05)., Conclusion: Patient Dyspnea Goal Response and Patient Global Impression seem to be relevant for evaluating the effects of a comprehensive management of symptoms, including dyspnea, assisting decision making process. Some factors may be implicated in determining the individual target and clinical response. A personalized symptom goal may translate in terms of therapeutic intervention, according to the achievement of the patients' expectations. High values of dyspnea intensity, a lower Karnofsky level, as well as high level of Dyspnea Intensity Goal (that is less patients' expectations) favor the achievement of the target., (Copyright © 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A supportive palliative care unit (SPCU) may have a positive impact on patients' care. The aim of this study was to compare the pattern of patients admitted to a specialized SPCU and to a traditional oncologic ward (OW) in a consecutive sample of advanced cancer patients., Methods: Data on patients demographics, reasons for and kind of admission, care-giver, anticancer treatments, being on/off treatment or uncertain, origin setting, who proposed hospital admission, the use of opioids, and hospitalization were gathered. The same parameters were recorded at discharge. A follow-up was performed by phone 1 month after discharge., Results: Two-hundred patients were surveyed. Awareness of disease was more complete in OW patients (P = 0.001). Uncontrolled pain and symptoms were the prevalent reasons for admission to SPCU (P < 0.0005). Toxicity from chemotherapy was more frequently reported by OW patients (P = 0.001). SPCU patients received higher doses of opioids (P = 0.004). More SPCU patients were referred from home and were discharged home (P < 0.0005 and P = 0.018, respectively). Emergency admissions were more frequently reported in OW patients (P < 0.0005). One month after, more SPCU patients were at home and were still on active treatment (P = 0.002, and P = 0.05, respectively). More OW patients died within 1 month (P = 0.001)., Conclusion: SPCU allows a better planning admission to hospital and a better care trajectory in advanced cancer patients in comparison to a busy OW, where unselected emergencies more frequently occur.

Background: To assess the response to ketamine in patients with difficult pain syndromes., Methods: The charts of patients with uncontrolled pain despite opioid dose escalation of at least two opioids or a combination of them, selected for a burst of ketamine and midazolam were reviewed. One hundred mg/day of ketamine and midazolam 15 mg/day by a continuous intravenous infusion for about 48 hours was offered to patients., Results: Forty-four patients received a burst of ketamine. Ten patients did not achieve any improvement. Pain intensity decreased from a mean of 7.8 (SD, 1.6) to 2.8 (SD, 1.3) (P<0.0005). The outcome was considered optimal, good, and mild in 24, 9, and 1 patients, respectively. Adverse effects attributable to ketamine did not have relevant intensity and no patient discontinued the treatment due to psychomimetic adverse effects., Conclusions: This data suggests that a burst of ketamine and midazolam at low doses, may reverse an unfavourable opioid response, assisting the opioid switching. Although the role of ketamine remains controversial, it should not deter physicians to do not use that in specific conditions.

The aim of this cohort study is to compare the symptom burden of patients who have an unplanned admission to an acute palliative care unit (APCU) with patients who have a regular planned admission. A consecutive sample of advanced cancer patients who were admitted to an APCU was prospectively assessed. The reasons and the kind of admission were recorded (unplanned, UP, or planned, P). Anticancer treatments, whether patients were on/off treatment or uncertain, previous care setting, and who referred the patient to the unit were also recorded. The Edmonton Symptom Assessment Scale (ESAS) was used at admission and at time of discharge, as well as the Memorial Delirium Assessment Scale. Analgesics and their doses at admission and discharge were recorded. Hospital staying was also recorded. At the time of discharge, subsequent referral to other care settings, and the pathway of oncologic treatment were re-considered. Fifty-five (17.5%) of 314 consecutive admissions recorded in a period of 10 months were UP. UP-patients are more frequently referred from other hospitals (P = 0.0005), and are reported by physicians of other units (P = 0.05). UP-patients have a longer hospital admission (P = 0.032), a higher hospital death rate (P = 0.025), and are less frequently discharged home (P = 0.031). A significant decrease in intensity of ESAS items was observed in both groups, with no differences in symptom burden either at admission and time for discharge. At discharge, opioid doses are higher in UP-patients. An APCU may admit UP-patients at any stage of disease, providing effective treatment outcomes, as reported with P-patients. This study suggests that patients referred from other settings or hospitals may provide specialist advice and rapid symptom control. Although symptom burden is similar, these patients have longer hospital admission, higher hospital death rate, and are less frequently discharged home, suggesting the need for more complex treatments. Such units in a comprehensive cancer center might improve symptom control and pose as referral centers for non-cancer hospitals, emergency departments, or the territory.

Aim: The aim of this prospective study was to determine the characteristics and symptom burden of advanced cancer patients with alcoholism problems and smoking, who were referred to an acute palliative/supportive care unit (ASPCU) of a comprehensive cancer center., Methods: Patients' characteristics, indications for admission, kind of admission, awareness of prognosis, and anticancer treatments were recorded. The Edmonton Symptom Assessment Scale (ESAS) was used to assess physical and psychological symptoms, and the CAGE questionnaire for the diagnosis of alcoholism. Patients were also divided in three groups: persistent smokers (PS), former smokers (FS), and non-smokers (NS). The Memorial Delirium Assessment Scale (MDAS) was used to assess the cognitive status of patients. Analgesic drugs and their doses at admission and discharge were recorded, as well opioid escalation index during hospital stay., Results: Three hundred fourteen consecutive cancer patients were surveyed. Forty-seven (14.9%), 143 (45.5%), and 124 (39.5%) subjects were PS-patients, FS-patients, and NS-patients, respectively. Sixteen patients were CAGE-positive. Females were more frequently NS, while males were more frequently FS (p = 0.0005). Statistical differences were also observed in disease awareness among the categories of smoking (p = 0.048). No statistical differences were found in ESAS items, except for drowsiness at T0 in NS-patients. Differences were found in OME and OEI, although the large variability of data did not determined a statistical difference. Higher values of nausea (at T0, p = 0.0005), dyspnea (at T0 and TX, p = 0.08 and 0.023, respectively), and well-being (at TX p = 0.003) were reported in CAGE-positive patients. No correlation was found between CAGE-positive patients and smokers., Conclusion: Although smoking and alcoholism have obvious implications in advanced cancer patients, data remain controversial, as present data did provide limited data to confirm risk factors for advanced cancer patients. Clinical response was not strongly influenced by these risk factors.

Background: Delirium is often unrecognized in cancer patients. The aim of this study was to investigate the prevalence of delirium assessed by the Memorial Delirium Assessment Scale (MDAS) and possible associated factors on admission to an acute palliative/supportive care unit (APSCU). The secondary outcome was to assess changes in MDAS and symptom burden at time of discharge., Methods: A consecutive sample of advanced cancer patients who were admitted to an APSCU was prospectively assessed for a period of 10 months. Patient demographics, including age, gender, primary diagnosis, Karnofsky status, stage of disease, and educational level were collected. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS were measured at hospital admission and discharge., Results: A total of 314 patients were surveyed. Of 292 patients with MDAS available at T0, 74 (25.3%) and 24 (8.2%) had a MDAS of 7-12 and ≥13, respectively. At discharge, there was a significant decrease in the number of patients with a MDAS ≥7/30. Higher values of MDAS were associated with age (p = .028), a lower Karnofsky status (p < .0005), gender (male, p = .04), low level of education (p = .002), less awareness of disease (p < .0005), more indications for end-of-life care admission (p < .0005) or other symptoms (p = .026), hospital stay (p = .038) and death (p < .0005). Significant decreases in ESAS were observed in all patients independently of MDAS values (p < .0005)., Conclusion: Delirium is highly prevalent in patients admitted to APSCU, characterized by a low mortality due to early referral. Comprehensive assessment and treatment may allow a decrease in the level of cognitive disorders and symptom burden.

Objectives: The aim of this study was to assess the characteristics of patients readmitted to an acute supportive/palliative care unit (ASPCU), the reasons for readmission, and the outcome after receiving specialistic assessment and treatment., Methods: A consecutive sample of patients was assessed for a period of 10 months. Epidemiological characteristics, including age, gender, Karnofsky level, diagnosis, caregivers, education, disease awareness, kind of admission, and anticancer treatment in the previous 30 days, were recorded, as well as hospital stay, death, and discharge at home. The principal reasons for admission were recorded. Symptom intensity and opioid doses, expressed as oral morphine equivalents, were also measured., Results: In the study period, 79 (25.2%) readmissions were recorded. Thirty-seven (46.8%) readmissions occurred within 30 days after discharge. Pain was more frequently reported as indication for admission at the first and the second readmission in comparison with the first admission. The burden of symptoms was significantly higher in patients with a readmission in comparison with patients at the first admission. Opioid doses, expressed as oral morphine equivalents, were significantly different between the first admission and readmissions. In both patients at the first admission or readmission, a significant decrease in symptom intensity has been reported at discharge., Conclusion: About 25% of patients discharged from an ASCPU are expected to be readmitted for reemerging of clinical problems. Re-exacerbation of pain seems to be the most frequent reason. A further clinical reassessment and treatment were equally effective in controlling the symptom burden of these patients at any readmission.

Context: Mesothelioma is a very aggressive cancer that is brought on by asbestos exposure. Because there is a long latency period between exposure to asbestos and symptoms of disease, most patients with mesothelioma present with advanced disease and survive an average of 8-12 months. Thus, best supportive care should be considered critical to optimally manage these patients., Aim: The aim of this study was to examine the epidemiological characteristics and symptom burden of mesothelioma patients when admitted to home palliative care., Methods: The charts of a consecutive sample of patients admitted to the home palliative care program with a diagnosis of mesothelioma in an endemic industrialized area were reviewed. The estimated survival time was about two months from admission. Epidemiological characteristics were collected. Karnofsky status, characteristics of pain and analgesic treatment at time of admission were recorded. ESAS (Edmonton Symptom Assessment System) and other clinical problems reported in the charts at admission time were also recorded., Results: Of the 674 charts reviewed, 56 patients (8.3%) had a diagnosis of mesothelioma. About three quarters of those had pain, with 18 and 2 patients with moderate and severe pain, respectively, despite receiving medium to high doses of opioids. The principal pain site was the chest. Pain was significantly associated with opioid consumption (p < .0005) and dyspnea (p = .049). Symptom burden was relevant, with a global ESAS of about 40. Pain, weakness, poor appetite, poor well-being, and dyspnea were the most frequent symptoms with the highest intensity; cough and pleural effusion were more frequently present as clinical problems., Conclusion: This study shows that mesothelioma is a devastating cancer with a relevant symptom burden, and that patients were referred to palliative care late in the course of their disease, suggesting that earlier integration of palliative care should be considered to relieve suffering in all disease stages - not only at the end of life.

Background: In the field of hemato-oncology, there is paucity of data assessing models of integration between hemato-oncology and other partner specialties. The aim of this national survey was to gather information about the status of the integration of this kind of activity in hemato-oncologic units existing in Italy., Methods: A national telephone survey was conducted to gather information about the status of the integration of hemato-oncologic and supportive care/anesthesiological services. From the national registry of hemato-oncology units, 149 centers were contacted by phone and a dedicated doctor was identified to gather information about the center through a telephone interview., Results: Eighty-one centers (54.3 %) agreed to participate. A mean of 206 (SD 132) painful procedures/year/center were performed. No significant differences among regions and centers were found (P = 0.680). Of the centers, 41.9 % usually asked for anesthesiological consultation to perform painful procedures. No differences were found between the regions (P = 0.137). A mean of 1.8 (SD 1.2) days elapsed from the request to the procedure performance (P = 0.271). No differences among the regions were found (P = 0.350). A mean of 220 (SD 89) central venous vascular accesses/year/center were performed. No differences among regions were found (P = 0.170). No differences among the centers were found (P = 0.691). A mean of 1.8 (SD 1.2) days elapsed from the request to the performance of procedure. Of the centers, 64.2 % had a palliative care team. No differences among regions were found (P = 0.331). A mean of 31.5 (SD 12.2) consultations/year/center for pain control were required. No differences among the regions were found (P = 0.556). Of the centers, 30.8 % had some beds for palliative care. No differences among the regions were found (P = 0.641). Of the centers, 32 % had a hospice was available. No differences among regions were found (P = 0.298)., Conclusion: Integration between hemato-oncology and other professionals is unlikely to be optimal in Italy. Such integration is complex and needs great efforts to solve several organizational problems.

Aim: The aim of this study was to assess how an admission to an acute palliative-supportive care unit (APSCU), may influence the therapeutic trajectory of advanced cancer patients., Methods: A consecutive sample of advanced cancer patients admitted to APCU was assessed. The following parameters were collected: patients demographics, including age, gender, primary diagnosis, marital status, and educational level, performance status and reasons for and kind of admission, data about care-givers, recent anticancer treatments, being on/off treatment or uncertain, the previous care setting, who proposed the admission to APSCU. Physical and psychological symptoms were evaluated at admission and at time of discharge. The use of opioids was also recorded. Hospital staying was also recorded. At time of discharge the parameters were recorded and a follow-up was performed one month after discharge., Results: 314 consecutive patients admitted to the APSCU were surveyed. Pain was the most frequent reason for admission. Changes of ESAS were highly significant, as well as the use of opioids and breakthrough pain medications (p <0.0005). A significant decrease of the number of "on therapy" patients was reported, and concomitantly a significant number of "off-therapy" patients increased. At one month follow-up, 38.9% patients were at home, 19.7% patients were receiving palliative home care, and 1.6% patients were in hospice. 68.5% of patients were still living., Conclusion: Data of this study suggest that the APSCU may have a relevant role for managing the therapeutic trajectory of advanced cancer patients, limiting the risk of futile and aggressive treatment while providing an appropriate care setting.

Context: Home care programs in Italy., Objectives: The aim of this study was to assess a protocol for palliative sedation (PS) performed at home., Methods: A total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam., Results: A total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P=0.012). The principal reasons to start PS were agitated delirium (n=20) and dyspnea (n=4). Mean duration of PS was 42.2±30.4 hours, and the mean doses of midazolam were 23-58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively., Conclusion: This protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Background: This survey was performed to draw information on pain prevalence, intensity, and management from a sample of patients who were admitted to an oncologic center where a palliative care unit (PCU) has been established for 13 years., Methods: Cross-sectional survey in an oncological department performed 1 day per month for six consecutive months., Results: Of the 385 patients, 69.1, 19.2, 8.6, and 3.1 % had no pain, mild, moderate, and severe pain, respectively. Inpatients and patients with a low Karnofsky score showed higher levels of pain intensity (p < 0.0005). One hundred twenty-eight patients with pain or receiving analgesics were analyzed for pain management index (PMI). Only a minority of patients had negative PMI score, which was statistically associated with inpatient admission (p = 0.011). Fifty of these 128 patients had breakthrough pain (BTP), and all of them were receiving some medication for BTP., Conclusion: It is likely that the presence of PCU team providing consultation, advices, and cultural pressure, other than offering admissions for difficult cases had a positive impact on the use of analgesics, as compared with previous similar surveys performed in oncological setting, where a PCU was unavailable. This information confirms the need of the presence of a PCU in a high volume oncological department.

The aim of this study was to present how opioids are used in an acute pain relief and palliative care unit (APRPCU), where many patients with difficult pain conditions are admitted from GPs, home palliative care programs, oncology departments, other hospitals or emergency units, and other regional places. From a consecutive sample of cancer patients admitted to an APRPCU for a period of 6 months, patients who had been administered opioids were included in this survey. Basic information was collected as well as opioid therapy prescribed at admission and, subsequently, during admission and at time of discharge. Patients were discharged once stabilization of pain and symptoms were obtained and the treatment was considered to be optimized. One week after being discharged, patients or relatives were contacted by phone to gather information about the availability of opioids at dosages prescribed at time of discharge. One hundred eighty six of 231 patients were specifically admitted for uncontrolled pain, with a mean pain intensity of 6.8 (SD 2.5). The mean dose of oral morphine equivalents in patients receiving opioids before admission was 45 mg/day (range 10-500 mg). One hundred seventy five patients (75.7 %) were prescribed around the clock opioids at admission. About one third of patients changed treatment (opioid or route). Forty two of 175 (24 %), 27/58 (46.5 %), 10/22 (45.4 %), and 2/4 (50 %) patients were receiving more than 200 mg of oral morphine equivalents, as maximum dose of the first, second, third, and fourth opioid prescriptions, respectively. The pattern of opioids changed, with the highest doses administered with subsequent line options. The mean final dose of opioids, expressed as oral morphine equivalents, for all patients was 318 mg/day (SD 798), that is more than six times the doses of pre-admission opioid doses. One hundred eighty six patients (80.5 %) were prescribed a breakthrough cancer pain (BTcP) medication at admission. Sixty five patients changed their BTcP prescription, and further 27 patients changed again. Finally, eight patients were prescribed a fourth BTcP medication. Of 46 patients available for interview, the majority of them (n = 39, 84 %) did not have problems with their GPs, who facilitated prescription and availability of opioids at the dosages prescribed at discharge. For patients with severe distress, APRPCUs may guarantee a high-level support to optimize pain and symptom intensities providing intensive approach and resolving highly distressing situations in a short time by optimizing the use of opioids.

The aim of this multicenter study was to assess the pattern and the characteristics of advanced cancer patients admitted to hospices. A consecutive sample of patients admitted in a period of 6 months was taken into consideration. Two hundred thirty-six patients admitted to hospices were consecutively assessed. Ninety-six percent of patients were admitted in acute hospital in the previous 3 months, with a mean time spent in hospital of 34.5 days, and 47 % of patients had received chemotherapy the month before hospice admission. Thirty-four percent of patients for whom data were available had significant persistent pain, and 44 % of them presented episodes of breakthrough pain. Sixty-one percent of patients were receiving opioid drugs at admission, and 70 % the day before death, with parenteral morphine and transdermal fentanyl being the opioids most frequently administered. The mean admission time in hospice was 18.4 days. Eighty-six percent died in hospice. Palliative sedation was performed in 25 % of patients who died in hospice. The short survival and the number of patients dying in hospice were the principal finding, as it appears that hospice admission is only one way for end of life treatments. Patients receive specialized palliative care only for 2-3 weeks before death, implying an inacceptable timing for patients with several problems presumed to be present early during the course of disease. Data from hospice activities in Italy strongly suggest to spread palliative care in other settings, other than home care and hospice, to intercept oncologic patients in their disease trajectory early.

Objectives: The aim of this study was to evaluate the opioid response in patients receiving morphine and pregabalin, independently from the presumed pain mechanisms, in comparison with patients receiving morphine treatment only., Methods: A multicenter prospective randomized controlled study was carried out in a sample of 70 advanced cancer patients with pain requiring strong opioids. Thirty-five patients (group MO) were randomized to receive sustained-release morphine using initial doses of 60 mg/day. Thirty-five patients (group MO-PR) were randomized to start the same morphine doses and pregabalin in increasing doses, starting with 25 mg/day up to 150 mg/day in one week. The following data were also recorded before starting the treatments (T0) and then at week intervals for four weeks (W1-4): age, gender, primary cancer and known metastases, pain causes and mechanisms, symptoms associated with opioid therapy, pain intensity, Brief Pain Inventory (BPI), morphine doses and escalation indexes (OEIs), and quality of life., Results: Forty-eight patients completed the study, twenty-eight and sixteen patients in group MO and MO-PR, respectively. Twenty patients were females, the mean age was 65.5 (± 10.3), and the mean Karnofsky status was 66.0 (± 18.9). No differences between groups were found in age (P = 0.839), Karnofsky status (P = 0.741), opioid doses as well as escalation indexes (OEI mg, P = 0.260, and OEI%, P = 0.270). No differences between the two groups were found in quality of life and all BPI items., Conclusion: The use of low doses of pregabalin added to morphine therapy in advanced cancer patients does not seem to provide advantageous analgesic effects, despite limitations of the present study due to the number of drop-outs.

Unlabelled: Despite the favorable effects reported with opioid switching performed in a specialized unit in the short term, data on long-term basis are poor, particularly after discharging patients home or in other settings., Research Design and Methods: The aim of this prospective study was to evaluate the long-term outcome of patients who were switched in an acute palliative care unit at a high volume of opioid switching. A consecutive sample of patients who underwent opioid substitution during admission in an acute palliative care unit were assessed for a period of 1 year. Patients were followed-up for 4 weeks after being discharged. Patients were contacted by phone or visited at the outpatient clinic 4 weeks after discharge. Epidemiological data, pain mechanisms, reason for switching, number of opioid substitutions during admission, drugs, doses and routes of administration, opioid treatment at discharge, pain intensity, distress score (DS) calculated as a sum of symptom intensity, were recorded after 2 weeks (T2) and 4 weeks (T4). A total of 76 patients underwent an opioid substitution in the period taken into consideration. Seventeen patients were excluded as they died in the unit or underwent an alternative procedure after unsuccessful opioid trials. A total of 50 patients were consecutively assessed and discharged after performing an opioid switching. The mean age was 63 (±11) years, and 29 were males. Of the 31 patients, 29 patients were switched during admission once and twice or more, respectively. In all, 32 patients had a complete assessment at T2 and T4. In 13 patients the switching was definitive, as they maintained the same drug and the same dose. Other patients required the same changes to opioid therapy, including doses and drugs. Only a minority of patients worsened their pain and/or symptom control in the subsequent assessments after discharge., Conclusions: Opioid switching performed in acute pain relief and palliative care is an effective method of improving the balance between analgesia and adverse effects, even for prolonged periods of time, following discharge to another setting of care. However, for different reasons, some of patients may lose this benefit. Additional studies using different models of care should be performed in order to gather further information about the long-term outcome of opioid switching.

Context: Data regarding the circumstances of the process of death of terminally ill patients followed at home are lacking., Objectives: The aim of this study was to describe the characteristics and assess the circumstances of the process of death of terminally ill patients followed at home., Methods: This was a prospective survey to assess the dying process of advanced cancer patients followed at home. Within a week after death, the principal caregiver was interviewed. Information from the palliative home care team and the caregiver about expectation of death, time of death, professional and nonprofessional people present at time of death, emergency admission to hospital, and administration of drugs to resuscitate was gathered. The principal clinical issues in the last two hours also were recorded., Results: In total, 181 of 222 caregivers provided information. Most deaths were expected. Palliative home care team physicians and nurses visited the patient on the day of death but were occasionally present at the moment of death. More than three people were generally present at time of death. More than two-thirds of patients died peacefully, without apparent suffering, and 35.7% of them received palliative sedation before dying. In the last two hours, the most frequent clinical issues were ranked as death rattle, dyspnea, and agitation. In 10 cases, emergency drugs for resuscitation were administered., Conclusion: This study has shown how advanced cancer patients die at home and that palliative home care may be helpful in allowing a death at home, particularly when relatives are actively involved., (Copyright © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

A retrospective study of patients who were prescribed controlled-release oxycodone (CRO) in a period of 3 years (2006-2008) was performed. A total of 212 patients were prescribed at discharge CRO for background analgesia; 129, 43, and 40 patients were prescribed doses of oxycodone of less than 120 mg/day (group L), 120 to 240 mg/day (group M), and more than 240 mg/day (group L), respectively. No differences in gender, primary diagnosis, and pain mechanisms were found, but doses were significantly lower in older patients (P < .0005). At discharge, adverse effects were mild and only a minority of patients were switched to other opioids. This study demonstrated that CRO administered in larger doses was safe and effective, showing versatility and flexibility similar to morphine.

The aim of this study was to assess the prevalence of opioid-induced dysuria in patients with advanced cancer having pain and to evaluate the possible factors associated. A consecutive sample of cancer patients admitted to an acute pain relief and palliative care unit during 8 months was surveyed. Most patients (147, 86.5%) were receiving opioids at admission. The mean age was 65.1 (SD 12.2) and 106 patients were males. Twenty-five patients presented with dysuria at admission (of which 22 were taking opioids, 14.9%). Eleven patients were inserted a bladder catheter at admission for urine monitoring and 18 patients had urinary incontinence. During admission, 31 patients presented dysuria (19% of population was taking opioids). The prevalence of dysuria was more frequent in males, in patients presenting pelvic masses or who had pelvic surgery, and patients with neurological deficits. Opioid switching during admission was correlated to the occurrence of dysuria. Patients with chronic cancer pain receiving opioid therapy present a prevalence of bladder dysfunction of about 15%, which is influenced by several concomitant factors. Given the complex clinical picture of advanced cancer patients, further studies should be performed to explore the presence of dysuria in patients with no pain and not receiving opioids to know the real weight of opioid therapy with respect to other variables.

The aim of this survey was to assess the opioid use in the last week of life of cancer patients admitted at an acute palliative care unit. From a consecutive sample of patients surveyed for a period of one year, patients who died in the unit were selected. Type of opioid, route of administration, and doses were recorded one week before death (or at admission time if the interval admission-death was less than one week) (-7), and on the day of death (Tend). Seventy-seven patients died in the unit in the period taken into consideration (12.4%). Oral morphine equivalents were 170 mg/day and 262 mg/day at -7 and Tend, respectively. Patients were receiving transdermal drugs or intravenous morphine at Tend, with a trend in the use of intravenous morphine at Tend (p=0.07). Intravenous morphine was more frequently used in sedated patients at Tend (p=0.015).No differences in age, gender, opioid doses, and OEI were found among opioids used. In patients who were sedated doses of opioids were significantly increased (p=0.012). In the last week of life intravenous morphine is the preferred modality to deliver opioids in an acute palliative care unit. Doses increases prevalently observed in sedated patients were performed before starting sedation with the purpose to treat concomitant distressing symptoms, such as dyspnoea.

Objectives: To determine the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP)., Methods: In 66 patients consecutive patients admitted to a pain relief and palliative care unit, the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP) were assessed. The choice of the opioid to be administered as rescue medication was based on the characteristics of patients, clinical stability, compliance, preference, and so on. For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to re-assess the patient 15 minutes after the opioid given as a rescue medication (T15)., Results: Six hundred twenty four episodes of BP were recorded during admission. Intravenous morphine (IV-MO) and oral transmucosal fentanyl (OTFC) were most frequently administered. Of 503 events available, 427 episodes were defined as successfully treated, while 76 episodes required a further administration of opioids. Pain intensity significantly decreased at T15 in all the groups (P<0.001). In 97.2% and 90.7% of cases treated with IV-MO, BP events had a reduction in pain intensity of more than 33% and 50%, respectively. In 99.2% and 97.6% patients receiving OTFC, BP events had a reduction in pain intensity of more than 33% and 50%, respectively., Discussion: This survey suggests that doses of opioids for BP proportional to the basal opioid regimen, are very effective and safe in clinical practice, regardless the opioid and modality used.

Terminally ill cancer patients near the end of life may experience intolerable suffering refractory to palliative treatment. Although sedation is considered to be an effective treatment when aggressive efforts fail to provide relief in terminally ill patients, it remains controversial. The aim of this study was to assess the need and effectiveness of sedation in dying patients with intractable symptoms, and the thoughts of relatives regarding sedation. A prospective cohort study was performed on a consecutive sample of dying patients admitted to an acute pain relief and palliative care unit within a cancer center. Indications for sedation, opioid and midazolam doses, level of delirium and sedation, nutrition, hydration, rattle, inability to cough and swallow, pharyngeal aspiration, duration of sedation and survival, and use of anticholinergics or other drugs were recorded. Family members were interviewed. Forty-two of 77 dying patients were sedated, and had a longer survival than those who were not sedated (P=0.003). Prevalent indications for sedation were dyspnea and/or delirium. Twelve patients began with an intermediate sedation, and 38 patients started with definitive sedation. The median sedation duration was 22 hours. Opioid doses did not change during sedation. Agitated delirium significantly decreased with increasing doses of midazolam, whereas the capacity to communicate concomitantly decreased. Interviewed relatives were actively involved in the process of end-of-life care, and the decision to sedate, and the efficacy of sedation, were considered appropriate by almost all relatives. Controlled sedation is successful in dying patients with untreatable symptoms, did not hasten death, and yielded satisfactory results for relatives. This study also points to the importance of palliative care and the experience of professionals skilled in both symptom control and end-of-life care.

The aim of this study was to prospectively evaluate the frequency, indications, outcomes, and predictive factors associated with opioid switching, using a protocol that had been clinically applied and viewed as effective for many years. A prospective study was carried out on a cohort of consecutive cancer patients who were receiving opioids but had an unacceptable balance between analgesia and adverse effects, despite symptomatic treatment of side effects. The initial conversion ratio between opioids and routes was as follows (mg/day): oral morphine 100=intravenous morphine 33=transdermal fentanyl 1=intravenous fentanyl 1=oral methadone 20=intravenous methadone 16=oral oxycodone 70=transdermal buprenorphine 1.3. The switch was assisted by opioids used as needed, and doses were changed after the initial conversion according to clinical response in an acute care setting. Intensity of pain and symptoms associated with opioid therapy were recorded. A distress score (DS) was calculated as a sum of symptom intensity. A switch was considered successful when the intensity of pain and/or DS, or the principal symptom necessitating the switch, decreased to at least 33% of the value recorded before switching. One hundred eighteen patients underwent opioid substitutions. The indications for opioid switching were uncontrolled pain and adverse effects (50.8%), adverse effects (28.8%), uncontrolled pain (15.2%), and convenience (4.2%). Overall, 103 substitutions were successful. Ninety-six substitutions were successful after the first switching, and a further substitution was successful in seven patients who did not respond to the first switch. The mean time to achieve dose stabilization after switching was 3.2 days. The presence of both poor pain control and adverse effects was related to unsuccessful switching (P<0.004). No relationship was identified between unsuccessful switching and the opioid dose, opioid sequence, pain mechanism, or use of adjuvant medications. Opioid switching was an effective method to improve the balance between analgesia and adverse effects in more than 80% of cancer patients with a poor response to an opioid. The presence of both poor pain relief and adverse effects is a negative factor for switching prognosis, whereas renal failure is not.

This randomized controlled study evaluated the role of corticosteroids as adjuvants to opioid therapy in 76 advanced cancer patients with pain who requiring strong opioids. Patients were divided in 2 groups. Group O received conventional opioid treatment. Group OS received dexamethasone (8 mg orally) along with conventional treatment. Pain and symptom intensity, sense of well-being, and opioid escalation index and distress score were recorded at weekly intervals until death. No differences in pain intensity, opioid consumption, and opioid escalation index were found in 66 patients who survived 33 to 37 days. Corticosteroids did not provide significant additional analgesia to opioids, but persistently decreased opioid-related gastrointestinal symptoms for the patients with limited survival and improved the sense of well-being for some weeks. Corticosteroid-related toxicity was minimal. Further studies with an increased sample size are necessary to detect any minimal difference in analgesia between the two groups.

Supplemental dosing of an opioid is the main treatment suggested to manage breakthrough pain in cancer patients. The intravenous route has been proven to be safe and effective, providing rapid analgesia in patients receiving oral morphine. Transdermal buprenorphine (TTS-BUP) is increasingly used in cancer pain management, but this drug has been labeled as a difficult drug to use in combination with other opioids. The aim of this open-label study was to verify the safety and effectiveness of intravenous morphine (IV-MO) for the treatment of episodic pain in cancer patients receiving TTS-BUP. A consecutive sample of 29 cancer patients, who were treated with TTS-BUP, reported an acceptable basal analgesia, and presented with episodic pains were selected for the study. The IV-MO dose was one-fifth of the morphine equivalent oral daily dose calculated using a ratio of TTS-BUP/oral morphine of 1:75, and a morphine IV/oral ratio of 1:3. For each episode, pain intensity and opioid-related adverse effects were recorded when severe pain occurred (T0), and 15 minutes after. One hundred six breakthrough events in the 29 patients (3.7 episodes per patient, on average) were recorded during admission. The mean pain intensity decreased from an initial value of 7.3 (confidence interval [CI] 95% 7.0-7.5) to 2.9 (CI 95% 2.5-3.3) 15 minutes after IV-MO. Ninety-eight episodes (92.4%) were considered treated successfully, defined as a reduction of more than 33% within 15 minutes; 88 of these episodes (83.0%) had more than 50% pain intensity decrease. No differences in age, gender, pain mechanism, and time of events were found. Eight episodes (7.5%) did not respond effectively within 15 minutes, and required further doses. The occurrence of adverse effects for each episode treated was not frequent and intensity was not relevant. IV-MO was effective and safe in most cancer patients receiving TTS-BUP who experienced pain exacerbation.

Hydration during palliative care is a controversial topic. Most of the arguments are based on anedoctal reports that have not been substantiated with scientific data. Given that the choice is problematic from a clinical perspective, preferences of patients and family should dictate whether intravenous fluids are administered. The aim of this study was to evaluate patient and family perceptions about hydration and two modes of providing hydration. Fifty-four consecutive patients admitted to an acute pain relief and palliative care unit who required hydration completed a questionnaire regarding their perceptions on hydration and modes of hydration. Similarly, the principal family carer was chosen and similar questions were posed. For most items, patients and relatives agreed, considering hydration as a useful medical treatment that is able to provide some nutrition. The intravenous route was considered able to improve the clinical condition and to have a positive psychological meaning, representing an acceptable burden. The subcutaneous route was considered less effective, and not less bothersome than the intravenous route. Most patients and relatives agreed with continuing hydration at home, if necessary, preferring the intravenous route. Other than technical considerations, which can be variable according to the clinical setting, the perceived benefits of artificial hydration by the caregivers and patients are central to the ethical, emotional, and cultural considerations involved in their decision making. Most patients and relatives surveyed accepted and were in favor of intravenous hydration.

Breakthrough pain is normally severe in intensity and has a rapid onset. The availability of supplemental doses of opioids (rescue medication) in addition to the continuous analgesic medication is the main treatment suggested to manage these pain flares. The intravenous (i.v.) route may provide analgesia fast enough, but has never been assessed in clinical studies. The aim of this open-label study was to verify the safety and effectiveness of an i.v. dose equal to one-fifth the calculated equianalgesic total daily dose in advanced cancer patients with episodic pain. A consecutive sample of 48 cancer patients treated with oral morphine, who reported an acceptable basal analgesia and reported episodic pains, were selected for the study. The intravenous dose of morphine was one-fifth of the oral daily dose, converted into an i.v. dose using an equianalgesic ratio of 1/3 (i.v./oral). Written orders were given and intravenous morphine (i.v.-M) was administered by nurses. For each episode, pain intensity and opioid-related symptoms were recorded at the start (T0), after achieving maximum pain relief (T1), and one hour after (T2). In five patients, blood samples were taken at the time intervals described for measuring plasma concentrations of morphine and related glucuronated metabolites. One hundred seventy-one breakthrough pains were recorded during admission. In 162 episodes, a reduction of pain intensity of more than 33% was obtained within a mean of 17.7 minutes, from a mean intensity of 7.9 (on a 0-10 numeric scale) to 3. One hundred thirty-six episodes had more than a 50% pain intensity decrease after the i.v.-M within a mean of 16.6 minutes, from a pain intensity of 7.9 to 2.6. No differences in age, sex, pain mechanism, and time of events were found. There was a trend but no statistically significant differences between the groups receiving different basal doses and time to reach the maximum effect. Twenty episodes in ten patients required an additional dose within 2 hours. Adverse effects were uncommon and were significantly related to the basal dose, and as a consequence, with the i.v.-M dose. Morphine concentration significantly increased at the time of pain intensity reduction, and then decreased. These observations suggest that i.v.-M at a dose equivalent to 20% of the basal oral dosage is safe and effective in the majority of patients experiencing pain exacerbation. This treatment is inexpensive and can be used at little risk to patients.

Simple Summary: Catastrophism was not associated with the levels of pain intensity, PSG, PSGR, and PGI for pain, except the rumination subscale that was independently associated with pain intensity at T0. A comprehensive palliative care management provided the relevant changes in symptom burden and annulled the pain expression associated with rumination. Background: Pain catastrophizing is a group of negative irrational cognitions in the context of anticipated or actual pain. The aim of this study was to decipher the possible role of catastrophism on pain expression and outcomes after a comprehensive palliative care treatment. Methods: A consecutive sample of patients with uncontrolled pain was assessed. Demographic characteristics, symptom intensity included in the Edmonton symptom assessment system (ESAS), and opioid drugs used were recorded at admission (T0). The Pain Catastrophizing Scale (PCS) was measured for patients. Patients were also asked about their personalized symptom goal (PSG) for each symptom of ESAS. One week after a comprehensive palliative care treatment (T7), ESAS and opioid doses used were recorded again, and the number of patients who achieved their PSG (PSGR) were calculated. At the same interval (T7), Minimal Clinically Important Difference (MCID) was calculated using patient global impression (PGI). Results: Ninety-five patients were eligible. A significant decrease in symptom intensity was reported for all ESAS items. PGI was positive for all symptoms, with higher values for pain, poor well-being, and poor sleep. Only the rumination subscale of catastrophism was significantly associated with pain at T0 (B = 0.540; p = 0.034). Conclusions: Catastrophism was not associated with the levels of pain intensity, PSG, PSGR, and PGI for pain, except the rumination subscale that was associated with pain intensity at T0. A comprehensive palliative care management provided the relevant changes in symptom burden, undoing the pain expression associated with rumination. [ABSTRACT FROM AUTHOR]

Aim: This study aims to determine the symptom burden of caregivers who were following their loved ones at home and factors associated with this burden. Methods: From a consecutive number of patients followed at home by a specialistic palliative care team, a sample of 46 couples of patients-caregivers was screened. Epidemiological data of both patients and caregivers were collected, also including some variables, such as the level of religiousness, education, economic conditions, and financial distress. The Edmonton Symptom Assessment System (ESAS) was measured in both patients and caregivers. Caregivers were asked to provide a comment in a semi-structured interview, about "what do you think of your loved one's suffering?" They were also invited to release any further comment. Results: Caregivers' symptom burden was relevant. Sleep disturbances were even more relevant in caregivers. Caregivers with a lower level of education and financial distress experienced more global symptom burden. Caregivers manifested a deep sense of injustice and gripes regarding previous hospitalizations. Conclusion: There is an association between patient-reported severity of symptoms and caregiver symptoms. These data suggest delivering support to those caregivers who express higher levels of symptoms. There is a need for further research to explore the possible interventions to mitigate caregivers' symptom burden. [ABSTRACT FROM AUTHOR]

Aim: To assess patients' barriers to pain management and analgesic medication adherence in patients with advanced cancer. Methods: This was a prospective cross‐sectional study in patients with advanced cancer receiving chronic opioid therapy. Age, gender, cancer diagnosis, Karnofsky level, and educational status were recorded. The Brief Pain Inventory (BPI), Edmonton Symptom Assessment Scale (ESAS), Memorial Delirium Assessment Scale (MDAS), Barriers Questionnaire II (BQ‐II), Medication Adherence Rating Scale (MARS), and Hospital Anxiety and Depression Scale (HADS) were the measurement instruments used. Results: One‐hundred‐thirteen patients were analyzed. The mean age was 68 (±13) years, and 59 (52%) were male. The mean Karnofsky status was 51.4 (standard deviation [SD] 11.5). The mean score for BQ‐II items was 1.77 (SD 0.7). The BQ‐II score was independently related to the HADS‐Depression score (P = 0.033) and the total HADS score (P = 0.049). Negative side‐effects and attitudes toward psychotropic medication globally prevailed among MARS items. These items were independently associated with gender (P = 0.030), pain (P = 0.003), and depression (P = 0.047). Conclusion: Barriers to pain management were mild. Psychological factors such as depression were the main factor associated with barriers. Poor adherence to analgesic medication was mostly manifested as negative side‐effects and attitudes toward psychotropic medication, was more frequent observed in females, and was associated with the ESAS items pain and depression. [ABSTRACT FROM AUTHOR]

The article discusses the efficacy and tolerability of tapentadol (TP) for a period of four weeks in patients treated by opioids. It mentions that sample of 30 patients who were receiving at least 60 milligram of oral morphine equivalent was selected for a prospective observational cohort study. It concludes that TP used in doses was tolerated and effective in opioid tolerant patients with cancer pain.

Aim: To characterize episodic breathlessness (EB) in patients with advanced cancer, and to determine factors influencing its clinical appearance. Methods: A consecutive sample of advanced cancer patients admitted to an acute palliative care unit was surveyed. Continuous dyspnea and EB were measured by a numerical scale. The use of drugs used for continuous dyspnea and EB was recorded. Patients were asked about the characteristics of EB (frequency, intensity, duration and triggers). The Multidimensional dyspnea profile (MDP), the Brief dyspnea inventory (BDI), the Athens sleep scale (AIS) and the Hospital Anxiety and Depression Scale (HADS) were also administered. Results: From 439 advanced cancer patients surveyed, 34 and 27 patients had EB, without and with background dyspnea, respectively. The mean intensity and the number of episodes were higher in patients with background dyspnea (p < 0.0005 and p = 0.05, respectively). No differences in duration were observed. Most episodes lasted <10 min. A recognizable cause triggering EB was often found. The presence of both background dyspnea and EB was associated with higher values of MDP and BDI. EB was independently associated with frequency and intensity of background dyspnea (OR = 20.9, 95% CI (Confidence interval) 9.1–48.0; p < 0.0005 and OR = 1.97, 95% CI 1.09–3.58; p = 0.025, respectively) and a lower Karnofsky level (OR = 0.96, 95%CI 0.92–0.98, p = 0.05). Discussion: EB may occur in patients with and without continuous dyspnea, and is often induced by physical and psychological factors. EB intensity is higher in patients with continuous dyspnea. The duration was often so short that the use of drugs, as needed, may be too late, unless administered pre-emptively when the trigger was predictable. [ABSTRACT FROM AUTHOR]

The characteristics of patients who had never received anticancer treatments at admission of an acute supportive palliative care unit (ASPCU) have never been explored. From a consecutive sample of 422 advanced cancer patients, 62 patients with no previous anticancer therapy were selected and compared with a random sample of patients who had received anticancer treatments. Age, gender, primary tumor, Karnofsky status, characteristics of admission, the level of education, economic status, awareness of disease, the presence of cachexia, and comorbidities and palliative prognostic score, symptom intensity, opioid drugs used at admission, reasons for admission to APSCU were recorded in both groups. At time of discharge, ESAS and analgesic drugs used were recorded again. Discharge modalities were also recorded. One month after the end of recruitment period (the last patient enrollment), a follow-up was performed by phone contacts with relatives to assess survival at three months after discharge. Patients without previous anticancer therapy (14.7%) were mainly admitted to ASPCU for a low Karnofsky level and high symptom burden, often waiting for or needing a histological diagnosis to make a decision for the next therapeutic steps. This group of patients were older (P <0.0005), more frequently males (P =0.007), and had more comorbidities (P <0.0005) in comparison with treated patients. Twenty-four per cent of these patients started chemotherapy subsequently. Treatment-naive patients had a higher level of symptom burden, which was less responsive to a comprehensive palliative and more frequently died within three months in comparison with treated patients. Treatment-naive patients showed a higher level of symptom burden, which was less responsive to a comprehensive palliative treatment. In addition they more frequently died within three months in comparison with treated patients. [ABSTRACT FROM AUTHOR]

An integrated score, taking into account pain and adverse effect intensity, provides simple data easy to compare in research studies of opioid switching for cancer pain. Evaluation of opioid switching (OS) for cancer pain has not been properly assessed. The aim of this study was to assess an integrated score (Maddalena Opioid Switching Score) as a simple and repeatable tool to evaluate the outcomes of OS, facilitating the interpretation and comparison of studies, and information exchange among researchers. The integrated score took into account pain intensity, intensity of opioid-related symptoms, and cognitive function by using an author's formula. Physical and psychological symptoms were evaluated by the Edmonton Symptom Assessment Scale and Patient Global Impression (PGI) by the minimal clinically important difference. One hundred six patients were analyzed. Ninety-five patients were switched successfully, and 11 patients underwent a further OS and/or an alternative procedure. The Maddalena Opioid Switching Score significantly decreased after OS and was highly correlated to PGI of improvement (P < 0.0005). In patients with unsuccessful OS, no significant changes in the Maddalena Opioid Switching Score and PGI were observed. A significant reduction in Edmonton Symptom Assessment Scale items intensity was observed after OS. The Maddalena Opioid Switching Score resulted to be a sensitive instrument for measuring the clinical improvement produced by OS. [ABSTRACT FROM AUTHOR]