影响晚期癌症伴慢性中重度疼痛患者镇痛效果的因素分析

目的 探讨影响晚期癌症伴慢性中重度疼痛患者镇痛效果的相关因素,为晚期癌症姑息治疗提供一些参考。方法 收集260例晚期恶性肿瘤伴有慢性中重度疼痛患者的相关资料,所有患者均进行规范化镇痛治疗。以疼痛强度数字分级法评分降至≤3分,爆发痛次数≤3次/日,解救治疗次数≤3次/日作为疼痛控制良好的指标,以镇痛3天疼痛控制情况、镇痛时间、镇痛药物剂量作为评价镇痛难易的指标。分析性别、年龄、肿瘤类型、有无骨转移、疼痛强度、疼痛部位、疼痛原因、疼痛机制及有无频发爆发痛（每天3次以上）对镇痛效果的影响。结果 260例患者镇痛治疗3天疼痛控制良好率为75.4%（196/260）,中位镇痛时间为2天。Logistic回归及Cox回归分析结果显示,消化系统肿瘤、重度疼痛和频发爆发痛是导致镇痛3天疼痛控制不佳（P＜0.05）及镇痛时间长（P＜0.05）的独立危险因素,而性别、年龄、骨转移、疼痛部位、疼痛原因和疼痛机制对镇痛3天疼痛控制情况及镇痛时间长短无显著影响（P＞0.05）。185例应用强阿片类药物患者中,年龄＜60岁（P=0.018）、重度疼痛（P＜0.001）、存在神经病理性疼痛（P=0.002）及频发爆发痛（P=0.015）的患者需止痛药物剂量大,而性别、肿瘤类型、骨转移、疼痛部位、疼痛原因对镇痛药物剂量无显著影响（P＞0.05）。结论 年龄＜60岁、消化系统肿瘤、重度疼痛、存在神经病理性疼痛及频发爆发痛为影响镇痛效果的危险因素。     

Breakthrough pain in cancer patients

Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. A typical episode of breakthrough pain has a fast onset and short duration, yet despite the self-limiting nature of each breakthrough pain, the repeated episodes can have a significant effect on patients’ quality of life. Normal-release oral opioids have been the mainstay pharmacological approach for patients who are receiving an around the clock opioid regimen, but the onset and duration of action of oral opioids such as morphine may not be suitable for treating many breakthrough pains. Efforts to provide non-parenteral opioid formulations that could provide more rapid, and more effective, relief of breakthrough pain have led to the development of transmucosal opioid formulations.     

癌症爆发痛的现状和研究进展

虽然癌症患者的基础疼痛控制相当稳定,但也可能会遭受短暂的疼痛加重,即癌症爆发痛。典型的爆发痛有快速发作和持续时间短等临床特征,这种疼痛对患者生活质量和卫生资源的不良影响显而易见。即释型口服阿片类药物目前已广泛用于爆发痛的治疗,但其起效时间及作用持续时间长的特点并不适合治疗大部分的爆发痛。相比之下一些芬太尼制剂,如芬太尼透黏膜口含剂(oral transmucosal fentanyl citrate,OTFC)、芬太尼口腔泡腾片(fentanyl buccal tablet,FBT)、芬太尼舌下含片(sublingual fentanyl citrate,SLF)和芬太尼鼻喷雾剂(intranasal fentanyl spray,INFS)等,为癌症爆发痛的治疗带来了令人欣慰的疗效。另外,国内对布托啡诺鼻喷剂治疗癌症爆发痛也已有一定的研究。     

Treating breakthrough pain in oncology

Introduction: Breakthrough cancer pain (BTcP) is an episode of severe intensity in patients receiving an adequate treatment with opioids able to provide at least mild analgesia. BTcP is a heterogeneous condition as episodes vary between individuals. The aim of this article is to review the pharmacologic options for the management of BTcP.

Areas covered: Recent reviews revealed that transmucosal preparations of fentanyl provided superior and more rapid pain relief as compared to placebo and oral morphine within the first 30 min after dosing. Few comparison studies among fentanyl products have been performed. Although dose titration has been recommended for years, a meaningful dosing, according to the level of opioid tolerance, may enhance the advantages of such products

Expert commentary: BTcP represents a relevant problem reported by many cancer patients despite receiving regular use of opioids. Different modalities of pharmacological interventions are available. In comparison with oral opioids, fentanyl preparations appear to have a short onset and offset of analgesic effect, fitting the temporal characteristics of BTcP. Further studies are warranted to assess the net benefit of these drugs to assist decision-making by patients, clinicians, and payers, according to individual clinical conditions.     

慢性顽固疼痛患者芬太尼透皮贴剂的门诊治疗

目的:观察门诊慢性疼痛患者用芬太尼透皮贴剂(Transdermalfentanyl,TDF)的镇痛疗效。方法:选择慢性顽固性疼痛患者416例,其中中、晚期癌症性疼痛占314例,非癌性疼痛102例,使用TDF止痛。对治疗前后的疼痛强度、生活质量评价及用药中的不良反应,进行观察和统计分析。结果:癌性疼痛治疗前疼痛视觉模拟评分(VAS)为7.94±1.15,治疗后降低至1.64±1.71;非癌性疼痛治疗前为7.30±1.54,治疗后降低至1.91±1.53。癌性疼痛的明显缓解率为51.5%,完全缓解为19.7%,总缓解率71.2%。非癌性疼痛明显缓解率为45.0%,完全缓解13.7%,总缓解率58.7%。生活质量治疗前后均变化(P<0.01)。用药的不良反应与传统的阿片类药物相似,为便秘、恶心、呕吐、头晕等症,但程度较轻;未出现呼吸抑制者。治疗后需停药的患者无身体及精神戒断症状发生。结论:TDF具有无创性、不间断的给药途径,镇痛效果确实,不良反应发生率低,患者依从性好,适合门诊、家庭应用。     

奥施康定联合静脉注射吗啡治疗癌痛及爆发痛的临床研究

目的 研究奥施康定联合静脉注射盐酸吗啡注射液在癌痛及其爆发痛的初始治疗阶段的疗效。方法 回顾我科2011年1月—2015年11月住院治疗的中重度癌痛患者78例,阿片类药物的剂量滴定应用奥施康定作为背景阿片药物,联合静脉注射吗啡治疗爆发痛,对疗效及药物应用的情况进行分析。结果 在疼痛滴定或再次滴定的前5天内累计每个患者应用阿片类药物的等效剂量(MED)为156~1 491 mg(426.46±286.00 mg),爆发痛解救应用的吗啡注射液剂量为2~57 mg(20.96±13.25 mg);夜间(20时~次日8时)爆发痛解救应用吗啡注射液人均剂量为2.23±2.50 mg,高于白天(8时~20时)剂量1.96±2.14 mg(P＜0.05),治疗后NRS评分与治疗前比较均明显降低,治疗前后对比均具有统计学差异(P＜0.05)。结论 奥施康定联合静脉注射吗啡治疗中重度癌痛及爆发痛是一种安全高效、简单易行的方法,显著改善患者的生活质量,是中重度癌痛滴定治疗阶段的首选方案。     

Breast Pain Associated with Mammographic Compression

Firm breast compression during film-screen mammography is necessary to achieve optimum image quality while minimizing radiation time. Of 374 women who fully completed a questionnaire following mammography, 225 (60%) reported no pain, 115 (31%) moderate pain and only 3 (1%) reported severe pain. Only one patient stated that the pain from the procedure would prevent her from having a further mammogram. Underlying breast disease (usually fibmystic disease) is associated with a greater incidence and severity of breast pain, but, no relationship has been demonstrated with regards to the patient's age, hormonal status, menstruation or caffeine intake. The high level of acceptance of firm compression by women in our study indicates that undue concern regarding patient discomfort should not deter people from referral for mammography or from the application of firm compression.     

电针联合疼痛贴对骨癌痛大鼠的抗抑郁作用机制

目的 观察电针联合疼痛贴对骨癌痛大鼠的抗抑郁作用并探讨其可能的机制。方法 建立大鼠胫骨癌痛模型，随机分为模型组、电针治疗组、疼痛贴治疗组、电针联合疼痛贴治疗组，另设空白组。造模成功后给予对应干预，观察胫骨癌痛模型大鼠行为学的改变。采用HPLC检测基底杏仁核脑组织中单胺类神经递质的变化、Elisa检测氧化应激水平的变化，Western blot检测凋亡蛋白的表达。结果 旷场实验中模型组大鼠的活动里程低于空白组，悬尾实验、强迫游泳实验中模型组大鼠的不动时间均高于空白组（P<0.01）。模型组5-HT、NE、DA含量均低于空白组（P<0.01），MDA含量和Caspase-3表达均高于空白组、CAT活性和Bcl-2表达均低于空白组（P<0.01）。旷场实验中三组治疗组的大鼠活动里程均高于模型组，悬尾实验、强迫游泳实验中三组治疗组的大鼠不动时间均低于模型组；三组治疗组的5-HT、NE、DA含量均明显高于模型组，MDA含量和Caspase-3表达均低于模型组，CAT活性和Bcl-2表达均高于模型组（P<0.01）。结论 电针治疗、疼痛贴治疗以及联合治疗可以改善胫骨癌痛模型大鼠的抑郁样行为学改变，其机制与缓解疼痛纠正脑内单胺类神经递质平衡失调、抗氧化应激和减轻神经细胞凋亡有关。     

地佐辛联合舒芬太尼治疗癌痛的临床效果

目的 探讨地佐辛联合舒芬太尼治疗癌痛的临床效果.方法 将80例癌痛患者随机分为3组,Ⅰ组采用0.3 mg/kg地佐辛治疗,Ⅱ组采用2.0μg/kg舒芬太尼治疗,Ⅲ组采用0.3 mg/kg地佐辛+2.0μg/kg舒芬太尼联合治疗.记录所有患者药物治疗前后生命体征的变化,用药后2、4、12、24、48 h的VAS镇痛评分和Ramsay镇静评分,以及用药后不良反应的发生情况.结果 3组患者用药前后生命体征均无明显变化(P>0.05),3组患者的VAS镇痛评分与治疗前比较明显下降(P<0.05),Ⅲ组各时段VAS镇痛评分均明显低于其他2组(P<0.05),且镇静评分及不良反应与其他两组比较无明显差异(P>0.05).结论 地佐辛联合舒芬太尼对癌痛的治疗效果好,且未增加不良反应,可以安全用于晚期癌症患者.     

187例癌痛患者对癌痛控制认识调查分析

文章分析了杭州城区与东阳市癌痛患者187例的癌痛控制状况，对癌痛治疗方案的认识以及使用鸦片类药物的情况．为今后进一步做好癌痛控制工作提供依据。     

中医药联合三阶梯止痛法治疗癌性疼痛的探讨

癌性疼痛是晚期肿瘤患者常有的临床症状,不仅严重影响患者的生存质量,而且不利于肿瘤的进一步治疗。文章着重讨论了中医药及三阶梯止痛法治疗癌性疼痛的利弊,两者联合使用可各取所长,互补其短,达到最佳止痛效果,从而达到无痛生存,提高生活质量的目的。     

博宁及博宁联合化疗治疗骨转移引起疼痛的疗效观察

目的：观察博宁单独使用与博宁联合化疗对实体瘤骨转移引起疼痛的疗效。方法：对４４例实体瘤骨转移患者随机分为治疗组（博宁单独应用）与对照组（博宁联合化疗）静脉滴注博宁９０ｍｇ，２至４周重复，对照组于次日行常规方案化疗（２周期）。结果：治疗组１８例，显效８例，有效６例，无效４例，总有效率７７．８％（１４／１８），一周内取得疗效占５０％（９／１８），毒副反应２例占１１．１％（２／１８），对照组２６例，显效     

丁丙诺啡与吗啡联合用于大鼠骨癌痛治疗的疼痛行为学观察

目的 观察不同剂量的丁丙诺啡与吗啡联合应用于大鼠骨癌痛的疼痛行为学变化,为临床合理应用阿片类药物治疗癌痛提供参考。方法 选择成年雌性Wistar大鼠进行实验,应用Walker256细胞建立骨癌痛模型,将骨癌痛大鼠分为5组,每组8只,分别于每日7:00 am和19:00 pm进行皮下注射,连续7日。吗啡组（M组）：吗啡10 mg/kg;吗啡+丁丙诺啡1组（MB1组）：吗啡10 mg/kg+丁丙诺啡20μg/kg;吗啡+丁丙诺啡2组（MB2组）：吗啡10 mg/kg+丁丙诺啡40 μg/kg;吗啡+丁丙诺啡3组（MB3组）：吗啡10 mg/kg+丁丙诺啡60 μg/kg;假手术组（Sham组）：皮下注射0.9%氯化钠溶液1 ml。全部大鼠于建模第15天开始,每日给药前30 min、给药后30 min进行疼痛行为学测定,包括甩尾实验、机械性痛觉敏感度测定、热痛觉敏感度测定。结果 给药7天内,机械痛阈和甩尾实验测定抗伤害痛阈结果显示,各MB组与M组给药后痛阈差异均无统计学意义;热痛阈结果显示：MB2组出现明显的热痛阈下降较M组晚（第6天vs.第5天）。结论 骨癌痛大鼠癌痛治疗时,丁丙诺啡与吗啡联合应用镇痛作用相似且可延缓吗啡的耐受发生。     

Practising Physicians' Experiences of Treating Patients with Cancer Pain

To elucidate the reasons for the undertreatment of cancer pain in Finland, a questionnaire survey was made of the experiences of 421 physicians. Their view on the role of the medical authorities, the problems experienced in pain treatment, their opinion about drug abuse and side effects of analgesics and the influence of basic and postgraduate education were requested. Seventy-six percent of the respondents reported difficulties in cancer pain treatment. The main problems seemed to be inefficacy of the therapy, mentioned by half of the respondents, side effects of analgesics (18%), and difficulties in the follow-up (9%) and the psychological support (7%) of the patients. Twenty percent of the physicians reported drug dependence among their cancer patients, but a detailed analysis of the problem revealed that in most cases the physicians used the term for tolerance or withdrawal symptoms. The physicians' own clinical experience, postgraduate education and the example of colleagues were the principal sources of information in cancer pain treatment. It is reasonable to assume that treatment of terminal cancer pain can be more successful within medical practice, provided teaching and training within the field is reinforced.