Controlling breakthrough pain in palliative care

This article challenges the common practice of boosting the syringe driver as a means of controlling breakthrough pain. The authors offer some guidelines for good practice for managing the MS26 syringe driver when used for pain control.     

The Philippines: status of cancer pain and palliative care

Syntheses of some 6-methyl-2-pyridinecarboxylic acid derivatives in condensation reaction of selected amines and alcohols with acyl chloride and mixed anhydrides were described.     

Quality assurance in palliative care: some of the problems

Twenty four patients with pure motor neuropathy are reported. The chronic motor involvement associated with fasciculations and cramps, mainly in the arms, led, in most patients, to an initial diagnosis of motor neuron disease. In some patients (nine of 24), there was no appreciable muscle atrophy. Tendon reflexes were often absent or weak. The finding of persistent multifocal conduction block confined to motor nerve fibres raises questions about the nature and the importance of this syndrome. Segmental reduction of motor conduction velocity occurred at the site of the block, but significant slowing of motor nerve conduction was not found outside this site. The response to intravenous IVIg treatment seems to be correlated with the absence of amyotrophy. Patients with little or no amyotrophy had an initial and sustained response to IVIg, and did not develop amyotrophy during the follow up study. They could be considered to have a variant of chronic inflammatory demyelinating polyneuropathy. Patients with pronounced amyotrophy independent of the disease duration did not respond as well to IVIg treatment, suggesting the existence of a distinct entity. Among the patients treated about two thirds who had an initial good response to IVIg had high or significant antiganglioside GM1 (anti-GM1) antibody titres, but there was no correlation between the high titres before treatment and long lasting response to IVIg treatment.     

Evaluation of a palliative care service: problems and pitfalls

OBJECTIVE: To evaluate a palliative care home support team based on an inpatient unit. DESIGN: Randomised controlled trial with waiting list. Patients in the study group received the service immediately, those in the control group received it after one month. Main comparison point was at one month. SETTING: A city of 300,000 people with a publicly funded home care service and about 200 general practitioners, most of whom provide home care. MAIN OUTCOME MEASURES: Pain and nausea levels were measured at entry to trial and at one month, as were quality of life for patients and care givers' health. RESULTS: Because of early deaths, problems with recruitment, and a low compliance rate for completion of questionnaires, the required sample size was not attained. CONCLUSION: In designing evaluations of palliative care services, investigators should be prepared to deal with the following issues: attrition due to early death, opposition to randomisation by patients and referral sources, ethical problems raised by randomisation of dying patients, the appropriate timing of comparison points, and difficulties of collecting data from sick or exhausted patients and care givers. Investigators may choose to evaluate a service from various perspectives using different methods: controlled trials, qualitative studies, surveys, and audits. Randomised trials may prove to be impracticable for evaluation of palliative care.     

Evaluating palliative care education

This paper illustrates the evaluation of some of the effects of a 3-day workshop for principals and trainees in general practice on a number of aspects of palliative care, using pre-, immediate and late post-tests. Further qualitative evaluation is attempted by including a questionnaire with the late post-test. The evaluation is to demonstrate significant shifts, or differences, in confidence in dealing with physical and psychosocial symptoms, and in participants' perceived ability to cope, and to support these findings with qualitative data where appropriate.     

The pitfalls of palliative care

An eight-year-old Highland pony which had previously shown normal laryngeal function, underwent general anaesthesia for surgical treatment of a mandibular sinus. During its recovery from the anaesthesia, the pony suffered great respiratory distress and stridor, due to total bilateral laryngeal paralysis and pulmonary oedema. The animal was immediately given a temporary tracheostomy. Some hours later, postoperative myositis developed; it resolved within two days and the pony's laryngeal function returned to normal during the following year.     

Psychosocial aspects of palliative care

The metabolites of [2,3-14C]acrolein in the urine and feces of Sprague-Dawley rats were identified after either intravenous administration in saline at 2.5 mg/kg or oral administration by gavage as an aqueous solution as either single or multiple doses at 2.5 mg/kg or as a single dose of 15 mg/kg. Selected urine and feces samples were pooled by sex and collection interval and profiled by combinations of reverse-phase, anion-exchange, cation-exchange, and ion-exclusion high-performance liquid chromatography (HPLC). Feces were also profiled by size-exclusion chromatography. Metabolites were identified by comparison with well-characterized standards by HPLC and by mass spectrometry. The urinary metabolites were identified as oxalic acid, malonic acid, N-acetyl-S-2-carboxy-2-hydroxyethylcysteine, N-acetyl-S-3-hydroxypropylcysteine, N-acetyl-S-2-carboxyethylcysteine, and 3-hydroxypropionic acid. The fecal radioactivity from the oral dose groups was partitioned into methanol-soluble, water-soluble, and insoluble radioactivity, some of which could be liberated by dilute acid hydrolysis. HPLC analysis of these extracts revealed no discrete metabolites. Size-exclusion chromatography indicated a molecular weight range of 2,000 to 20,000 Da for the radioactivity, which was unaffected by hydrolysis at reflux with 6 M acid or base. This radio-activity was thought to be a homopolymer of acrolein, which was apparently formed in the gastrointestinal tract. The pathways of acrolein metabolism were epoxidation followed by conjugation with glutathione, Michael addition of water followed by oxidative degradation, and glutathione addition to the double bond either following or preceding oxidation or reduction of the aldehyde. The glutathione adducts were further metabolized to the mercapturic acids.