Journal of Pain and Symptom Management

Acupuncture: What Does the Most Reliable Evidence Tell Us? A Correction

Adrian White — 2012-05-01

In a letter entitled “Acupuncture: What Does The Most Reliable Evidence Tell Us? An Update,” Ernst reported the headline results from Cochrane reviews on acupuncture that had been published or updated since his previous similar review in 2007. The percentage with positive results increased from 16% in 2007 to 29% in 2012.

Author's Reply

Edzard Ernst — 2012-05-01

Adrian White has a point, of course, but how relevant is it? It should not distract from my argument. Many systematic reviews of acupuncture (and other forms of Traditional Chinese Medicine) do include a multitude of methodologically weak Chinese studies. Acupuncture already has its fair share of biased reports, for example, Cummings and Kavoussi, and we should strive to reduce not increase bias. As I wrote in my Letter to the Editor, “The advantage of reviewing these studies is that they become accessible to a non-Chinese-speaking audience. The disadvantage is that neither the referees for the Cochrane Review nor its readers are likely to have access to the primary data.” My central message, however, was that acupuncture is, in most areas, not well supported by evidence. It is surprising that White thinks “The percentage with positive results has increased from 16% in 2007 to 29% in 2012.” Surely the 2012 evidence has to include all the 46 current Cochrane reviews rather than just the new ones. This would mean that the percentage is not 29% but 22%.

Illness Perceptions, Adjustment to Illness, and Depression in a Palliative Care Population

2012-01-30

Abstract: Context: Representations of illness have been studied in several populations, but research is limited in palliative care.Objectives: To describe illness representations in a population with advanced disease receiving palliative care and to examine the relationship between illness perceptions, adaptive coping, and depression.Methods: A cross-sectional survey of 301 consecutive eligible patients recruited from a palliative care service in south London, U.K. Measures used included the Brief Illness Perception Questionnaire (Brief IPQ), the Mental Adjustment to Cancer (MAC) Scale, and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire-9.Results: Scores were not normally distributed for most questions on the Brief IPQ. The correlations found between items on the Brief IPQ were understandable in the context of advanced disease. MAC helplessness-hopelessness and fighting spirit were highly correlated with items on the Brief IPQ in opposite directions. The Brief IPQ domains of consequences, identity, concern, personal control, and emotion were associated with depression, a relationship that was not explained by adaptive coping. Seven causal attribution themes were identified: don’t know, personal responsibility, exposure, pathological process, intrinsic personal factors, chance, fate or luck, and other. Both lung cancer diagnosis and gender were found to be independently associated with personal responsibility attribution. None of the attribution themes were associated with the presence of depression.Conclusion: Assessment of illness perceptions in palliative care is likely to yield important information about risk of depression and will help clinicians to personalize management of advanced disease.

Episodic (Breakthrough) Pain Prevalence in a Population of Cancer Pain Patients. Comparison of Clinical Diagnoses With the QUDEI—Italian Questionnaire for Intense Episodic Pain

2012-05-01

Abstract: Context: Breakthrough/episodic pain (BP-EP) diagnosis is often based on clinical experience, and different opinions exist, even among palliative care clinicians, about its definition and application to clinical practice.Objectives: The primary aim of this study was to assess the prevalence and clinical characteristics of BP-EP in an unselected Italian population of patients with cancer-related chronic pain, based on clinical diagnosis and on the use of an assessment tool, the Questionnaire for Intense Episodic Pain (QUDEI).Methods: A cross-sectional multicenter prevalence study of 240 consecutive cancer pain patients was carried out. The physicians participating in the study attended a training session aimed at defining and recognizing BP-EP. The QUDEI, a screening and assessment tool based on patient interview, diagnosed the presence of BP-EP in patients regularly taking analgesics for the previous three days and who had at least one pain flare in the previous 24 hours. Clinical evaluation and questionnaire application were carried out by different health care providers.Results: The estimated prevalence of BP-EP was 73% (95% confidence interval [CI]=67%, 79%) when the diagnosis was made by physicians and 66% (95% CI=60%, 72%) when the QUDEI was applied (86% agreement). When only patients with baseline pain less than or equal to six were included in the analysis, the above prevalences decreased to 67% and 60%, respectively.Conclusion: Because BP-EP is a significant phenomenon in cancer pain management, its appropriate recognition requires a more widely, internationally accepted general definition and specific validated tools for its screening and evaluation.

Comparisons of Exercise Dose and Symptom Severity Between Exercisers and Nonexercisers in Women During and After Cancer Treatment

Maria H. Cho, Marylin J. Dodd, Bruce A. Cooper, Christine Miaskowski — 2012-03-21

Abstract: Context: Although numerous studies of the efficacy of exercise are reported, few studies have evaluated changes in characteristics of exercise dose in women with cancer both during and after cancer treatment.Objectives: To describe the characteristics of exercise dose (i.e., frequency, duration, and intensity) and evaluate for differences in symptom severity (i.e., fatigue, sleep disturbance, depression, and pain) between women who did and did not exercise during and after cancer treatment.Methods: In a sample of 119 women, two groups were classified: exercisers and nonexercisers. Exercisers were defined as women who met specific criteria for frequency (three times per week), duration (20minutes/session), intensity (moderate), and mode (aerobic). Nonexercisers were defined as women who did not meet all these criteria. Evaluation of exercise dose was completed at baseline (T1: the week before chemotherapy cycle 2), at the end of cancer treatment (T2), and at the end of the study (T3: approximately one year after the T1 assessment) using self-report exercise questionnaires.Results: Approximately 50% of the participants exercised during treatment and 70% exercised after treatment. At T1, exercisers had lower total fatigue, lower behavioral and sensory subscale fatigue scores, and lower depression scores (P=0.038) than nonexercisers. No significant differences in sleep disturbance or pain were found between groups. At T2, exercisers had lower cognitive/mood subscale fatigue and depression scores than nonexercisers (P=0.047). At T3, no significant differences were found between groups in any symptom severity scores.Conclusion: Both during and after cancer treatment, achieving or maintaining exercise guideline levels were met by most patients. Further study is needed to examine the link between exercise dose and symptom severity.

The Meaning of Parenteral Hydration to Family Caregivers and Patients With Advanced Cancer Receiving Hospice Care

2012-03-29

Abstract: Context: In the U.S., patients with advanced cancer who are dehydrated or have decreased oral intake almost always receive parenteral hydration in acute care facilities but rarely in the hospice setting.Objectives: To describe the meaning of hydration for terminally ill cancer patients in home hospice care and for their primary caregivers.Methods: Phenomenological interviews were conducted at two time points with 85 patients and 84 caregivers enrolled in a randomized, double-blind, controlled trial examining the efficacy of parenteral hydration in patients with advanced cancer receiving hospice care in the southern U.S. Transcripts were analyzed hermeneutically by the interdisciplinary research team until consensus on the theme labels was reached.Results: Patients and their family caregivers saw hydration as meaning hope and comfort. Hope was the view that hydration might prolong a life of dignity and enhance quality of life by reducing symptoms such as fatigue and increasing patients’ alertness. Patients and caregivers also described hydration as improving patients’ comfort by reducing pain; enhancing the effectiveness of pain medication; and nourishing the body, mind, and spirit.Conclusion: These findings differ from traditional hospice beliefs that dehydration enhances patient comfort, given that patients and their families in the study viewed fluids as enhancing comfort, dignity, and quality of life. Discussion with patients and families about their preferences for hydration may help tailor care plans to meet specific patient needs.

An Assessment of the Screening Performance of a Single-Item Measure of Depression From the Edmonton Symptom Assessment Scale Among Chronically Ill Hospitalized Patients

Steven Z. Pantilat, David L. O’Riordan, Suzanne L. Dibble, C. Seth Landefeld — 2012-05-01

Abstract: Context: Few studies have examined the validity of using a single item from the Edmonton Symptom Assessment Scale (ESAS) for screening for depression.Objectives: To examine the screening performance of the single-item depression question from the ESAS in chronically ill hospitalized patients.Methods: A total of 162 chronically ill inpatients aged 65 and older completed a survey after admission that included the well-validated, 15-item Geriatric Depression Scale (GDS-15) and four single-item screening questions for depression based on the ESAS question, using two different time frames (“now” and “in the past 24 hours”) and two response categories (a 0–10 numeric rating scale [NRS] and a categorical scale: none, mild, moderate, and severe).Results: The GDS-15 categorized 20% (n=33) of participants as possibly being depressed with a score ≥6. The NRS for depression “now” achieved the highest level of sensitivity at a cutoff≥1 (68.8%), and an acceptable level of specificity was obtained at a cutoff of ≥5 (82.2%). For depression “in the past 24 hours,” a cutoff of ≥1 achieved a sensitivity of 68.8% and a cutoff of ≥7 a specificity of 80.3%. For the categorical scale, a cutoff of “none” provided the best level of sensitivity for depression “now” (65.6%) and “in the past 24 hours” (81.3%), with an acceptable level of specificity being obtained at ≥“mild” (68.8%) and ≥“moderate” (68.8%), respectively.Conclusion: These single-item measures were not effective in screening for probable depression in chronically ill patients regardless of the time frame or the response format used, but a cutoff of ≥5 or “mild” or greater did achieve sufficient specificity to raise clinical suspicion.

Influence of Patient Coaching on Analgesic Treatment Adjustment: Secondary Analysis of a Randomized Controlled Trial

2012-05-01

Abstract: Context: For patients with cancer-related pain and their physicians, routine oncology visits are an opportunity to adjust the analgesic regimen and secure better pain control. However, treatment intensification occurs haphazardly in practice.Objectives: To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits, and in turn, the influence of treatment adjustment on subsequent cancer pain control, we studied patients enrolled in a randomized trial of TEC.Methods: Just before a scheduled oncology visit, 258 patients with at least moderate baseline pain received TEC or control; just after the same visit, they reported on whether the physician recommended a new pain medicine or a change in dose of an existing medicine. Pain severity and pain-related impairment were measured two, six, and 12 weeks later.Results: Patients assigned to TEC were more likely than controls to report a change in the analgesic treatment regimen (60% vs. 36%, P<0.01); significant effects persisted after adjustment for baseline pain, study site, and physician (adjusted odds ratio 2.61, 95% confidence interval 1.55, 4.40, P<0.01). In a mixed-effects repeated measures regression, analgesic change (but not TEC itself) was associated with a sustained decrease in pain severity (P<0.05).Conclusion: TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing, and treatment intensification is associated with better cancer pain outcomes.

Education in Advanced Disease

Kate Flemming, S. José Closs, Robbie Foy, Michael I. Bennett — 2012-05-01

Abstract: Context: In advanced disease, the management of symptoms and lifestyle are essential for the maintenance of patients’ quality of life. Appropriate education by health professionals can help patients to better manage their disease. Although the provision of education by health professionals for patients with advanced cancer is reasonably well documented, much less is known about how health professionals facilitate education with patients with other advanced progressive diseases.Objectives: The aim of this review was to synthesize qualitative research examining health professionals’ knowledge of, attitudes toward, and ability to deliver educational interventions for symptom and disease management to patients with advanced progressive diseases other than cancer.Methods: The synthesis was conducted using meta-ethnography. Systematic searching of five electronic databases (CINAHL, Medline, PsycInfo, Web of Science Social Science Citation Index, and EMBASE) was performed. Included studies were data extracted and assessed for quality.Results: Systematic searching of four electronic databases identified 911 records; 17 studies met review inclusion criteria and underwent data extraction and quality appraisal. Three key factors were identified that influenced the delivery of education by health professionals to patients with advanced disease: capacity (to educate and aid decision making), context (of educational delivery), and timing (of education).Conclusion: Health professionals identify and acknowledge a range of factors that influence their ability to deliver education to patients with advanced disease. The types of circumstantial factors identified in this review can influence the successful delivery of educational interventions and need to be considered when such interventions are being developed.

Refining a Checklist for Reporting Patient Populations and Service Characteristics in Hospice and Palliative Care Research

2012-03-23

Abstract: Context: In specialist hospice and palliative care services, variations occur in diagnoses and prognoses of subpopulations referred, service configuration, and the health systems delivering care. These three levels of variation limit the ability to generalize study findings.Objectives: This article reports on coding one year of palliative care research using a previously developed checklist. The aims were to 1) quantify current reporting of factors related to generalizability in specialist palliative care research; 2) review and potentially refine the checklist in light of the first aim; 3) demonstrate the feasibility of collecting these data; and 4) set out simple processes to aid researchers in reporting, and clinicians in applying, new research evidence in hospice and palliative care.Methods: A previously published checklist (five domains, 14 core subdomains, and 24 noncore subdomains) was used to code all research articles (n=189) published in 2007 in the three leading palliative care research journals.Results: The most frequently reported subdomains were patient age, gender, and diagnosis; model of service delivery; and patient performance status. Data in subdomains, including time from referral to death, socioeconomic indices, and ethnicity, were rarely reported; none reported whole-of-service or whole-of-population data. In total, 2646 (189×14) core subdomains could have been reported. Data were provided in 28% (746/2646).Conclusion: Checklists such as the Consolidated Standards of Reporting Trials evaluate study design, focusing mainly on internal validity. The proposed checklist deals with specific content of hospice and palliative care, focusing on external validity.

Development of a Rural Palliative Care Program in the Calgary Zone of Alberta Health Services

Ron Spice, Linda Read Paul, Patricia D. Biondo — 2012-05-01

Abstract: Specialized rural models of palliative care are greatly needed to address the challenges rural communities face in providing palliative care services and to ensure that their unique strengths and needs are considered. In late 2005, a Rural Palliative Care Program was developed to support primary care providers in delivering palliative care to patients in rural communities outside of Calgary, Alberta, Canada. The program was grounded in the needs of individual communities, incorporated integral roles for local champions, and adopted pre-existing, accepted rural structures and processes. Needs and gaps in rural palliative care service delivery were identified and prioritized. The following actions were taken to address the top six priorities: 1) more accessible palliative care education opportunities with a rural focus were provided to health care professionals; 2) linkages with rural and urban resources were strengthened and access to specialists and procedures was improved; 3) strategies were implemented to improve psychosocial support for patients and families; 4) resources were developed to facilitate rural home deaths; 5) opportunities were expanded for education and utilization of volunteers; and 6) a mobile specialist consultation team was developed to support rural health care professionals and their patients in their rural communities. In its first four years, the team consulted on 640 patients, nearly three-quarters of whom died in their rural communities. Rather than imposing an urban outreach strategy, the development of a rural-based program through respectful engagement of local providers has proven to be crucial to the success of this rural palliative care program.

Consensus Recommendations From the Strategic Planning Summit for Pain and Palliative Care Pharmacy Practice

2012-05-01

Abstract: Pain and symptoms related to palliative care (pain and palliative care [PPC]) are often undertreated. This is largely owing to the complexity in the provision of care and the potential discrepancy in education among the various health care professionals required to deliver care. Pharmacists are frequently involved in the care of PPC patients, although pharmacy education currently does not offer or require a strong curriculum commitment to this area of practice. The Strategic Planning Summit for the Advancement of Pain and Palliative Care Pharmacy was convened to address opportunities to improve the education of pharmacists and pharmacy students on PPC. Six working groups were charged with objectives to address barriers and opportunities in the areas of student and professional assessment, model curricula, postgraduate training, professional education, and credentialing. Consensus was reached among the working groups and presented to the Summit Advisory Board for adoption. These recommendations will provide guidance on improving the care provided to PPC patients by pharmacists through integrating education at all points along the professional education continuum.

Changes in the Prescription of Psychotropic Drugs in the Palliative Care of Advanced Cancer Patients Over a Seven-Year Period

2012-03-21

Abstract: Context: Psychiatric disorders are frequently underdiagnosed and undertreated in advanced cancer patients.Objectives: To assess changes in the prescription of psychotropic drugs in terminally ill patients.Methods: All patients with advanced disease receiving palliative care between 2002 and 2009 were eligible. The consumption of benzodiazepines, antipsychotics, and antidepressants for the years 2002, 2006, and 2009 was compared. Data on the percentage and profile of psychotropic drugs prescribed were collected.Results: The study population included 840 patients (241 in 2002, 274 in 2006, and 325 in 2009). The percentage of patients treated with psychotropic drugs increased from 82.2% in 2002 to 90.2% in 2009 (P=0.006) and the mean number of drugs per patient from 1.66 in 2002 to 2.16 in 2006 (P=0.003), and to 2.35 in 2009 (P<0.001). Benzodiazepines were prescribed to 72.6% of patients in 2002 and 84% in 2009 (P=0.001), with lorazepam and midazolam as the most frequently used medications. The use of antipsychotics increased from 26.1% in 2002 to 37.2% in 2006 (P=0.007) and to 40% in 2009 (P=0.001), with haloperidol and risperidone as the most commonly prescribed. Antidepressants were prescribed to 17.8% in 2002, 28.1% in 2006 (P=0.006), and 27.1% in 2009 (P=0.010), with mirtazapine, citalopram, escitalopram, and duloxetine as the most frequent.Conclusion: Between 2002 and 2009, there was a significant increase in the use of psychotropic drugs and a change in the profile of drugs prescribed.

Parent Perceptions of Child Vulnerability Are Associated With Functioning and Health Care Use in Children With Chronic Pain

Mark Connelly, Kelly K. Anthony, Laura E. Schanberg — 2012-01-30

Abstract: Context: The extent to which parent variables are associated with the level of disability experienced by children with persistent pain has been an area of increasing research.Objectives: To evaluate the extent to which parent perceptions of their child’s vulnerability are associated with functioning and health care utilization among children with persistent pain. We also evaluated whether perceptions of child vulnerability contribute to an indirect relationship between parent distress and child functioning and/or child health care utilization.Methods: The study sample comprised 87 patients aged 6–18 years and a parent attending a chronic pain clinic. Children completed questionnaires on functional limitations, and parents completed questionnaires on parent distress, perceptions of child vulnerability, and extent of the child’s pain-related health care utilization. Hierarchical regression and bootstrapping mediation analyses were used to test study hypotheses.Results: Perceptions of child vulnerability were found to be clinically elevated in nearly half (46%) of parents/caregivers, and average child functional ability for the sample was substantially lower than healthy norms. Parent perceptions of greater child vulnerability were significantly associated with poorer child functioning and more child pain-related health care utilization regardless of child age, sex, and duration of persistent pain. Parent distress was found to be indirectly related to child health care utilization through parent perceptions of child vulnerability but directly related to child functioning.Conclusion: Parent perceptions of child vulnerability appear important for understanding levels of child functional limitations and health care utilization among children with chronic pain.

ABH Gel Is Not Absorbed From the Skin of Normal Volunteers

2012-05-01

Abstract: Background: Lorazepam (Ativan®), diphenhydramine (Benadryl®), haloperidol (Haldol®) (ABH) topical gel is currently widely used for nausea in hospice because of perceived efficacy and low cost and has been suggested for cancer chemotherapy. However, there are no studies of absorption, a prerequisite for effectiveness. We completed this study to establish whether ABH gel drugs are absorbed, as a prerequisite to effectiveness.Intervention: Ten healthy volunteers, aged 25 to 58 years (mean 37 years), two African Americans and eight Caucasian Americans, applied the standard 1.0mL dose (2mg of lorazepam, 25mg of diphenhydramine, and 2mg of haloperidol in a pluronic lecithin organogel), rubbed on the volar surface of the wrists by the subject.Measures: Blood samples were obtained at 0, 30, 60, 90, 120, 180, and 240 minutes. Plasma concentrations were analyzed by liquid chromatography-tandem mass spectrometry using deuterated internal standards for each drug.Outcomes: No lorazepam or haloperidol was detected in any sample from any of the 10 volunteers down to a level of 0.05ng/mL. Diphenhydramine was found in multiple plasma samples at concentrations >0.05ng/mL in three patients, with the highest concentration of 0.30ng/mL in one person at 240 minutes. Overall, five of 10 patients exhibited detectable diphenhydramine in one or more samples, supporting limited absorption. No subject noted any side effects.Conclusions/Lessons Learned: As commonly used, none of the lorazepam, haloperidol, or diphenhydramine in ABH gel is absorbed in sufficient quantities to be effective in the treatment of nausea and vomiting. Diphenhydramine is erratically absorbed at subtherapeutic levels. The efficacy of ABH gel should be confirmed in randomized trials before its use is recommended.

Unique Manifestations of Catecholamine Release in Malignant Pheochromocytoma: An Experience Within an Inpatient Palliative Care Unit

Nicholas Anthony Coupe, Judith Lacey, Christine Sanderson — 2012-01-30

Abstract: Malignant pheochromocytoma is a rare disorder. We describe the case of a 41-year-old female with disseminated metastatic pheochromocytoma who was admitted for ongoing palliative and supportive care within an inpatient palliative care unit. Predominant symptoms included severe gastrointestinal pseudo-obstruction and orthostatic hypotension Pseudo-obstruction management included percutaneous enterogastric and percutaneous enterojejunostomy tubes for gastric decompression and delivery of nutrition, respectively. Debilitating symptoms of orthostatic hypotension were mitigated with judicious fluid balance and appropriate use of adrenergic blocking agents. The potential for metoclopramide to worsen symptoms also was a significant component of management. The case presents rare features of this unusual disease and is unique for its setting within the confines of a palliative care unit.

In a Language Spoken and Unspoken: Nurturing Our Practice as Humanistic Clinicians

Karen Whitley Bell — 2012-05-01

Abstract: The health care industry and health care practitioners face significant challenges related to increasing demand for services and decreasing availability of resources. This article offers brief descriptions of four actions that health care leaders, administrators, and clinical staff of all disciplines can implement and/or advocate for to promote continuing quality of biopsychosocial/spiritual care for those we serve. The first action addresses how we, as health care practitioners, improve delivery of care through continuous improvement methodology; the second, how we enhance the training of our future workforce by increasing in-home training opportunities; the third, how we cost-effectively broaden our understanding of the human experience through the inclusion of humanities in our training and workplace; and the fourth, how we increase our self-awareness to improve our ability to practice as humanistic clinicians.

PC-FACS

Donna S. Zhukovsky — 2012-05-01

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members. Following are excerpts from recent issues, and comments from readers are welcomed at resources@aahpm.org.