BMJ Support Palliat Care 2:310-311 doi:10.1136/bmjspcare-2012-000372
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Articles of interest in other scholarly journals

  1. Jason Boland
  1. Senior lecturer and honorary consultant in palliative medicine, Hull York Medical School, University Of Hull, UK

Palliative sedation in end-of-life care and survival: a systematic review

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This systematic review aimed to compare the survival of sedated and non-sedated patients and analysed 11 articles (1807 patients; 621 sedated) including four prospective and seven retrospective non-randomised studies. Sedation was most frequently used for delirium at the end of life; other common reasons were dyspnoea, pain and psychological distress. Benzodiazepines were the most common drug group used, followed by antipsychotics. This review found no difference in survival of sedated and non-sedated patients, although it recognises the lack of randomised controlled trial evidence.

The disparity between patient and nurse symptom rating in a hospice population

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Although symptom rating should be by self-report these are often completed by nurses. This study compared the simultaneous symptom ratings of patients and nurses in 64 symptom ratings from 29 patients. There was more correlation for nausea, bowels, and breathing questions, and the least for appetite. There were wide differences in reporting and nurses generally underreported symptoms. The authors concluded that as the nurses’ symptom assessment only moderately correlates with patients’ symptom rating, this can misrepresent the patient's symptoms and self-reporting should be used unless the patient cannot do so.

Autonomic dysfunction in patients with advanced cancer: prevalence, clinical correlates and challenges in assessment

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In a prospective cohort study the risk factors for falls in 185 ambulant adult patients with advanced cancer were evaluated. Tests of autonomic function, symptom severity and muscle strength were used as well as 10-month survival. Forty-five percent were unable to complete all of the clinical tests of autonomic function due to frailty. Seventy-five percent of participants were accurately classified, of which 80% had autonomic dysfunction. Age and severity of fatigue were associated with having autonomic dysfunction and it is associated with reduced survival.

Antidepressants to cancer patients during the last year of life: a population-based study

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This study assessed the prescription of antidepressants in nearly 18 000 adults who died of cancer in Norway. Of these, 22% had been prescribed antidepressants in their last year of life (over three times that of the general population). The proportion was 20% in patients who died within a year from diagnosis and 23% in patients who had a longer duration of disease. Prescriptions increased in frequency toward death and 10% of antidepressants were prescribed for the first time in patients within 30 days of death, having questionable clinical effects.

Meta-analysis: non-steroidal anti-inflammatory drugs in biliary colic

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This systematic review with meta-analysis assessed the analgesic benefits and reduction of complications, as well as the potential harms from randomised clinical trials (RCTs) evaluating non-steroid anti-inflammatory drugs (NSAIDs) in biliary colic. Eleven RCTs with over 1000 subjects were included. In comparison with placebo, patients on NSAIDs were more likely to have complete pain relief and a lower rate of complications. In comparison with other drugs, NSAIDs were more efficacious in controlling pain than spasmolytics but there was no difference between NSAIDs and opioids. The authors conclude that NSAIDs are the first-line analgesic for patients with biliary colic as they control pain with the same efficacy as opioids and also reduce complications, but acknowledge the limitation of the lack of high-quality evidence with heterogeneity in the studies.

Longitudinal assessment of symptom severity among hospitalised elders diagnosed with cancer, heart failure, and chronic obstructive pulmonary disease

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In a prospective cohort study the prevalence, severity, burden and predictors of common symptoms during hospitalisation and 2 weeks after discharge in patients over 65 with cancer, heart failure and chronic obstructive pulmonary disease were determined. On admission, 54% reported moderate or severe pain, 53% dyspnoea and 62% anxiety; 64% had two or more symptoms at a moderate or severe intensity. The prevalence of moderate or severe symptoms decreased by around 50% during admission and at the 2-week follow-up. There was no association between diagnosis and symptom severity at or during admission but at 2 weeks more patients with chronic obstructive pulmonary disease had moderate or severe pain, dyspnoea and symptom burden compared with those with cancer or heart failure.

Emergency department visits for symptoms experienced by oncology patients: a systematic review

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This systematic review explored symptoms caused by cancer and its treatment at presentation to the emergency department. It included six prospective and 12 retrospective studies. Twenty-eight symptoms were reported, the most common being febrile neutropenia, infection, pain, fever and dyspnoea, although symptom definitions were inconsistent. Sixteen studies reported admission rates and showed that on average 58% of patients were admitted to hospital. Eleven studies reported mortality rates and showed an average of 13% (in multi-symptom studies) and 20% (in targeted symptoms studies) of emergency department presentations resulted in death.

Diagnosis and management of people with venous thromboembolism and advanced cancer: how do doctors decide? A qualitative study

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Using think aloud exercises and interviews of oncologists, palliative physicians and general practitioners, this study explored why clinicians did not always use low molecular weight heparin for cancer associated thrombosis despite high-level evidence. It found that clinicians are concerned with the patients’ prognosis, increased bleeding risk and burden of self-injection. Furthermore, the diagnosis and management of cancer-associated thrombosis can be complex and should be individualised on the risks/benefit for the patient. It was also found that, logistic and organisational issues also influenced investigation and treatment with low molecular weight heparin and the authors suggest that services are optimised to ensure that these do not hinder the appropriate investigation and management of patients.

Dissociable influences of opiates and expectations on pain

▸ [Abstract/FREE Full text]

The relationship between expectations and opioid analgesia were evaluated in healthy volunteers using a thermal pain model. Remifentanil was administered and participants’ knowledge of drug delivery was manipulated using an open–hidden design. Although remifentanil and expectancy both reduced pain, the effects of remifentanil on pain and functional MRI (fMRI) activity did not interact with expectancy. fMRI activity showed opioid-induced modulation during open and hidden conditions, with no differences in the effect of opioid caused by expectation, which followed a different time course from the opioid. The authors conclude that opioids and placebo influence pain reports and fMRI activity but that the effects of opioids and expectations did not interact.

Comparative health care use patterns of people with schizophrenia near the end of life: a population-based study in Manitoba, Canada

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Using the data repository at the Manitoba Centre for Health Policy, the health care services, including palliative care, accessed for patients with and without schizophrenia in the last 6 months of life were compared. Compared with a matched cohort, patients with schizophrenia were over twice as likely to be in a nursing home and for over twice as long, they had more visits to general practitioners and psychiatrists but had fewer visits to other specialists, including palliative care and were less likely to be prescribed opioids, indicating poor end-of-life care for patients with schizophrenia.

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