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Cancer pain - treatment and assessment approaches

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CONTROL OF ONCOLOGIC ABDOMINAL PAIN WITH ENDOSONOGRAPHY-GUIDED CELIAC PLEXUS NEUROLISIS

Jose Celso Ardengh*, Inmar de Paula Posso. Maria Belen Salazar Posso, Escola Paulista de Medicina- Endoscopic Service UNI-FESP, Sao Paulo, Brazil.

Aim of Investigation: To evaluate the utility ofendosonography-guided ccliac plexus neurolisis with 98% dehydrated alcohol in the control of the oncologic abdominal pain.

Methods: Eight patients, 6 males and 2 females, mean age of 62.3 years (range 51 to 72 years), with chronic pancreatitis (1), gastric (2) or pancreatic cancer (5), with excruciating abdominal pain not controled with morfme, were treated. We used the Pcntax EG 36-UG endoscopy and Olympus NA10J-1 needle, to inject 20 ml of 98% dehydrated alcohol, across the gastric wall, in their celiac plexus. The intensity of pain was evaluated before and 2, 4, 8 and 12 weeks after the alcoholization using the analogic visual pain scale. The needs ofmorfine and other non-opioid analgesics to control the pain were evaluated too.

Results: In five patients (62.5%) the pain disappeared and the use ofmorfine was not necessary. In two patients (25%) the pain and the needs ofmorfine decreased during 4 weeks, but the excruciating pain came back, and was necessary another endosonography-guided alcoholization, and the pain and the needs ofmorfine decreased. In the patient with chronic pancreatitis the method did not work (12.5%). No complications related to endoscopic procedure were observed. The complication of the method was diarrhca observed in two patients (25%) during ten days after the procedure.

Conclusions: The endosonography-guided celiac plexus neurolisis is a very safe, effective and easy method to the management of the incoercible oncologic abdominal pain.

LATE SEQUELAE AFTER BREAST IRRADIATION

U.E. Kongsgaard. S. Bjergo, B. Enkstein*, S. Kvinnsland*, H.H. Lien*, M. Behn*, P. Brunsvig*, E. Hannisdal*, The Norwegian Radium Hospital, Oslo, Norway

Aim of Investigation: Despite the clinical benefit of irradiation of breast cancer, this treatment may produce sequelae that could compromise a patient's quality of life. We evaluated symptoms from late sequelae in a group breast cancer patient that had undergone irradiation.

Methods: 2113 patients were treated with either 4.3 GY x 10 (1496 pts) or 2.5 GY x 10 (617 pts) to the breast wall and/or regional lymph nodes. 450 of these patients were still alive at the end of 1996. From this group 361 patients were examined for late radiation side effects, 245 patients had received 4.3 GY x 10 and 119 had received 2.5 GY x 10. The median observation time was 16 years and 10 years respectively. The patients were examined clinically by an oncologist and physiotherapist. Radiologic evaluation of the thorax was performed. Self-evaluation regarding pain experience and interference of pain in the patient's life was achieved using the Brief Pain Inventory (BP1). Results: Arm-oedema, fractures of the ribs and impaired shoulder function were the three most objective factors predicting late radiation side effects. Pain interference in the patient's life evaluated by the BPI was characteristic in most patients. Despite a high sum on the BPI pain score, only 37% were on pain medication (15% on Paracetamol and 14% on Paracetamol + Codeine). Only 1.5% were taking opioids.

Conclusion: Late sequelae after breast irradiation is associated with physical and psychological distress compromising quality of life. These problems are possibly underestimated.

AN EFFICACY OF PALLIATIVE RADIATION THERAPY COMBINED WITH EPIDURAL OR INTRATHECAL ANALGESIA FOR THE TREATMENT OF INTRACTABLE CANCER PAIN DUE TO BONE METASTASIS

K. Ota, A. Namiki. Sapporo Medical Collage, Dept. of Anesthesiology, Sapporo, 060-0061, Japan.

Aim of Investigation: This study is introduced a clinical efficacy of palliative radiation therapy combined with epidural or intrathecal analgesia for intractable cancer pain due to bone metastasis as one ofmiiltidiscriminal cancer pain therapies.

Methods: 15 patients (7 men and 8 women, 37-73 years old) with cancer pain due to bone metastasis were enrolled. The 15 patients failed to start palliative radiation therapy because of the intractable pain. Respectively, 4 of the 15 patients had received intrathecal analgesia because of the ineffectiveness of epidural analgesia. The other patients received epidural analgesia. All patients were treated with continuous infusion of morphine (2-7 mg daily) and 1% lido-caine (0.5-2 ml/hr) through cither a epidural or intrathecal catheter.

Result: Excellent pain relief was obtained and the radiation therapy (8-40 Gly) was completely done in all patients. 9 of the 15 patients (60%) had good pain control until death after the therapy. 2 patients (13%) temporally decreased the pain. 4 patients (27%) were no responder to radiation therapy. 6 patients needed either epidural or intrathecal analgesia after the radiation therapy.

Conclusion: The intractable cancer pain per se is sometimes one of big hazards to perform palliative radiation therapy. In such cases, epidural or intrathecal anesthesia is a useful supportive method to accomplish the radiation therapy.

USEFULNESS OF THE AXIAL TOMOGRAPHIC IN THE NEUROLYTIC CELIAC PLEXUS BLOCK

Alvaro Sarmiento, Dept of Anaesthesiology Clinica Reina Sofia. Guillermo Trujillo, Dept of Diagnostics Images, Clinica Reina Sofia. Diagonal 127 A #31-48. Office. 218. Bogota, Colombia.

Introduction: There are different methods to perform a Neurolytic Celiac Plexus Block (NCPB) in managing cancer pain; anatomic references, fluoroscopy, ultrasonogram, an Axial Computed Tomography (CT). After using different methods, we chose CT because of its efficiency and visualisation ofretrocrural space, and then decide the best way of access.

Method: We performed 10 neurolysis in 11 patients in a period from Jan. 98 to Oct. 98, 8 patients with pancreas cancer and 2 patients with gall bladder cancer; in 1 patient with hepatocarcinoma, the block was not technically possible because anatomical change. Age ranges from 40 to 70 years old; with a distribution of 4:1, M:F, all the patients had previous abdominal CT and were being treated with opioids. We used a tomograph GE-9800, needles No. 22, longitude 15 cm, and non-ionic contrast media and 90% alcohol. The boarding was done with 8 patients anterior access and 2 patient posterior access. The volume administered ofneurolytic solution was 40 c.c.

Results: In 70% of the patients the pain intensity was lowered 7-8/10 to less than 5/10. We were able to reduce the dosage of opioids to 50%, and in 20% they were suspended. There was a 6-months follow up. Side effects: Pain in area of puncture 90%. for a week period Postural hypotension 50%, for the first 24 hours Diarrhea 40% for 1 week

Conclusion CT is a highly efficient method as a helpful tool in selecting more sure way of access according to the individual characteristics and needs of the patient.

EXTERNAL RADIOTHERAPY FOR CANCER PAIN CONTROL: THE OLD METHOD NOT TO FORGET

Dalia Skorupskiene. Oncology clinic, Kaunas Medical Univ Hospital, Kaunas 3007, Lithuania

Aim of Investigation To confirm the use of external palliative radiotherapy as one of the most effective methods of cancer pain control for the patients with bone and brain metastases. Methods. 164 patients with bone metastases and 121 patient with metastases in the brain were treated by telegammatherapy (Co60, 1,25MeV) in Kaunas Medical Univ Hospital in 1993-1998, using different fractionation schemes (2,3 or 4Gy daily) with summary doses varying from 10 to 40Gy.

Results 6 patients from the group with bone metastases refused the treatment after 1 -2 fractions (2-4Gy), 2 died dunng the treatment .The partial or complete response in terms of pain control was achieved for all the rest 156 patients, complete response-long-term pain control - for 85% of these patients These patients stopped using drug analgesics for 2-3 months, 11 patients- even 5-6 months, the rest of the patients were able to reduce the dose of opioids or restart using drugs of the second or first step of the WHO "analgesic ladder" 32 patients, who received biphos-phanates courses before the radiotherapy treatment, showed the same response. In the brain metastases group pain (headache) was named as the main symptom by 62 patients, others had occasional headaches The patients were treated with palliative radiotherapy (summary dose 30Gy, 3Gy daily) combining it with pharmacologi-cal dehydration (prednisolone, diuretics) Pain control was achieved for all these patients and at least temporally- regression of other neurological symptoms

Conclusions One of the main pain control methods together with pharmacologica! analgesics (WHO "analgesic ladder") remains palliative radiotherapy-widely available and very efficient, especially for the patients, who had developed bone and brain metastases The use of radiotherapy enables to reduce the doses of opioids and other drugs. The adequate symptomatic treatment, combining all earlier established and modem means and methods, not only enables to reach immediate improvement of patients' condition, but also increases their survival and quality of life

BREAST PAIN: CHARACTER, RELATION TO DIET AND THE PRESENCE OF BREAST CANCER

S A. Khan*. L Zych*, A V Apkanan, Depts of Surgery and Neurosurgery, SUNY Health Science Center, Syracuse, New York, USA

Aim: The population incidence of breast pain (BP) is unknown, but it is a common complaint, present in 30% of new patients seen at our Breast Care Center. We have begun a study of the characteristics ofBP, relation to diet, and to the presence of breast cancer

Methods Patients with BP were identified from the Breast Care Center database A modified version of the short form of the McGill Pain Questionnaire and a short diet questionnaire were sent by mail to 600 patients Responses in 192 women who did not have breast cancer were analyzed The larger database was analyzed to examine the relationship between BP and breast cancer

Results. The mean intensity of the pain was 4 9 (scale 0-10) The mean present pain index was 2 (scale 0-5), and best descriptors were aching, heavy, and tender The pain was worst on the 23rd day of the menstrual cycle, with a mean duration of 10 2 days/cycle BP impact on quality of life (QOL) was 1 6 (scale 0-4) The mean painful area extended over 30% of the two breasts The size of the painful area was inversely related to the extent of throbbing (r = -0 27, p<0 02) and correlated with impact on QOL (r = 0 26, p<0 05) Diet There was an inverse correlation between consumption of dairy foods and sensory magnitude of pain (r= -0 14, p<0 05) Soy consumption was positively correlated with periodicity ofBP (r=0 13, p<0 05) Cancer The odds ratio (OR) for breast cancer in women with or without BP was calculated for 4681 patients The age adjusted OR of a breast cancer diagnosis for women with BP was 0 42 (95% CI 0 34-0 51)

Conclusions Breast pain has a significant adverse impact on quality of life Dietary habits seem to impact the intensity ofBP, and its presence may be protective against breast cancer

PAIN IN PATIENTS WITH CANCER ATTENDING A LYMPHOEDEMA CLINIC

Todd M, Welsh J, Mane Curie Centre Hunters Hill, Glasgow, Division of Palliative Medicine Univ of Glasgow, Scotland

Aim of Study To characterise the features of pain in cancer patients with lymphoedema attending a specialist lymphoedema clinic

Method This was a retrospective case note review of all patients with pain attending the lymphoedema clinic at a specialist palliative care unit

Results 75 patients with pain were identified, 60 were female and 15 male The average age was 63 years The commonest cancer was breast 39 (52%) followed by prostate 7 (9%), ovary and mela-noma 4 (3%) each Somatic pain occurred in 22 (29 3%) cases, bone pain in 20 (26 7%) and ncuropathic pam in 17 (22 7%) The commonest site of pain was the lymphoedematous arm, but there was a total of 7 different sites Symptoms attributable to lymphoedema which were said to be uncomfortable were heaviness of affected limb (65 3%) and tightness (29 7%) Analgesics prescribed were non-steroidal anti-inflammatory agents (21%), adjuvants (15%), opioids for moderate pain (13%) and opioids for severe pain (15%) 13% had inappropriate prescribing Metastases were the cause of pain in 20% of patients, lymphoedema in 21 3%, nerve damage in 5 3% and cancer unrelated conditions in the remainder Only 1 cancer patient in remission received an opioid for severe pain whereas in the advanced palliative group (50% of the total) 11 were on opioids for severe pain The difference is significant (p<0 001) The mean dose of morphine oral equivalent was 107mg/24hrs The palliative group had more severe lymphoedema with an average excess volume of 67% compared to those with stable disease whose excess volume was 20% (p<0 001)

Conclusion Lymphoedema patients with advanced cancer are likely to have a larger excess volume in the affected limb, are more likely than lymphoedem patients with stable disease to have severe pain and require opioids for severe pain Despite the presence of other sites of pain the affected limb is a significant source of pain

PAIN AND SYMPTOMS IN CHILDREN WITH CANCER AGED 7-12: VALIDATION OF A SYMPTOM ASSESSMENT QUESTIONNAIRE

CollinsJJ. Devine TB, Dick GS, Johnson EA, Pmkerton R, Portenoy RK, Thaler HT, The New Children's Hospital, Sydney Westmead, NSW 2124, Australia

Aim of Investigation To validate a questionnaire to assess pain and other symptoms in young children with cancer Methods A validated pain and symptom assessment scale, the MSAS, was shortened, revised and tested for validity and reliability in children aged 7-12 Summary scores for each of the 8 symptom were computed analogous to the original MSAS Demographic and clinical data were collected from parents and the medical record

Results A convenience sample of 10 inpatients and 80 outpatients at the Royal Marsden Hospital, London, reported an average of 1 8 symptoms MSAS 7-12 in an average of 7 minutes 1/3 reported pain; approximately half rated their pain as being moderately severe to severe and highly distressing 91% had little or no difficulty completing the questionnaire. The overall group of 8 symptoms had a Cronbach alpha coefficient ofO 73 74 patients repeated the MSAS 7-12 within a few days Correlation between baseline and re-test overall scores ranged from 0.21 for Worry to 0.65 for Sleep There were no significant differences in mean scores between baseline and re-test Factor analysis suggested that the symptoms tended to group in pairs as Pain and Sleep, Sad and Worry, and Tired and Eating Children with hematologic tumors were more Sad and patients who had undergone chemotherapy within the previous 7 days scored higher on Tired and Eating.

Conclusions A shortened symptom assessment scale is feasible, reliable and valid for young children An additional 50-90 children are being studied at the New Children's Hospital, Sydney West-mead, Australia

CHRONIC PAIN ASSOCIATED WITH OVARIAN ANTI-CANCER THERAPIES

Nicolae Georgescu-Tulcea. Cancer Dept, St Luca's Hosp, Tulcea, Romania

Aim of Investigation The chronic abdominal pain is frequent in ovarian cancer st III Supplementary, post laparatomy +/- surgical cite reduction are registered the chronic post-operatory pain, post chemotherapy are registered analgesia if they cause significant tumor shrinkage

Methods From January 1994 to January 1999, 179 patients with ovanan cancer were treated in Cancer Dept, St Luca's Hospital, Tulcea (st 1-5, st 11-14, st 111-122, st IV-38) The pain evaluation methods used were the visual analogue scale, the Wisconsm-Madison brief pain inventory, the Memorial Pain Assessment Card and the Romanian version of the McGill Pain Questionnaire

Results The ovanan st III cancer treatment were firstly laparatomy associated with maximal surgical cite reduction and secondly chemotherapy (1994-1997 CDPP + CPM; 1998 TAXOTERE+ FARMARUBICIN+DEXAMETHAZON) The incidence of different kinds of pain associated with ovanan anti-cancer therapy were mixed pain (MP) 51,6%; neuropathic pain (NO) 38,5%; nocicep-tive pain (NOP) 9,8% The treatment on NOP required opioids (morphine clorhidrate i m versus MST). NP were treated by association ofbicyclic antidepressant and anticonvulsants with Biop-tron-light therapy The management ofMP required both of the therapeutics

Conclusions. MP is the most frequent chronic pain associated with ovarian st III anti-cancer therapies This pain has a particular intensity, semiology and thopographic distribution, with regard to volume of residual disease The management of this pain requires the association of several therapeutics which can provide an adequate relief.

THE IMPACT OF A COMPREHENSIVE EVALUATION IN PATIENTS WITH CANCER AND PAIN

Paolo L Manfredi, MD, Sonja Chandler PharmD, MS, Richard Payne, MD

Objectives To evaluate the impact of a comprehensive evaluation of patients with cancer and pain

Methods All consecutive patients with cancer referred to the Pain and Symptom Management Service (PSMS) over five months were evaluated by two neurologists Demographic and clinical data were entered in a computenzed database

Results Over five months 187 patients with cancer and pain wereevaluated Diagnostic studies were ordered by the PSMS in 62 or 33% of all patients. Neural tissue injury was the pnmary cause of pain in 57 or 30% of patients and substantially contributed to the pain of an additional 46 or 25% of patients with mixed somatic anc neural tissue injury. A new diagnosis was made in 49 or 26% ofal patients. A new diagnosis was made in 44 patients or 43% of he 103 patients with neural tissue injury A new diagnosis was made in 5 or 6% of the 84 patients with somatic or visceral tissue injury.

Conclusion The spinal cord and the penpheral nervous system are frequently involved, often at multiple levels, in the pathophysio-logy of pain syndromes in patients with cancer A thorough pain evaluation of hospitalized patients with cancer leads to new diagnoses in a high percentage of cases of patients with neural tissue injury

GENDER DIFFERENCES IN THE PAIN EXPERIENCE OF CANCER PATIENTS WITH BONE METASTASIS

Chnstme Miaskowski. Claudia West*, Marylm Dodd*, Steve Paul*, Peter Koo, Debu Tripathy*, Schools of Nursing, Medicine, and Pharmacy, Univ of California, San Francisco, CA

Aim of Investigation To determine if gender differences exist in pain intensity scores, pain interference scores, analgesic prescriptions, mood states, and quality of life (QOL) in oncology outpatients who were expenencmg pam from bone metastasis.

Methods Patients completed the Bnef Pain Inventory (BPI), a Pair Medication Diary, the Profile of Mood States (POMS), and a revised Multidimensional Quality of Life Scale (MQOLS) on entry into the study T-tests and Chi square analyses were performed to evaluate for gender differences in the dependent variables Results: Women (n=81) were significantly younger than men (n=41) and had lower Kamofsky Performance Status Scores. No gender differences were found in any of the pdin intensity scores); in any of the pain interference items from the BPI except sexual activity (men reported greater interference with sexual activity); in any of the subscale and total mood disturbance scores on the POMS; in QOL score, or in the amounts of opioids prescnbed or administered

Conclusions Previous studies demonstrated that females are more sensitive to acute painful stimuli and in clinical situations report higher pain intensity scores. However, many of the clinical studies evaluated for gender differences in acute pain (e.g , acute postoperative pain). Findings from our study suggest that the gender differences observed with acute pain are not found with a chronic paii condition like metastatic bone pain In addition, while other studies reported a nsk for women with cancer pain to be undertreated, we did not observe this gender bias

Acknowledgments Funded by the National Cancer Institute CA64734

DIFFERENCES BETWEEN RUSSIAN AND AMERICAN PATIENTS SUFFERING CANCER RELATED PAIN

Galma Nazarenko*. Kolpmo Hospice, St Petersburg, Russia, Ralph N Wharton,W Crawford Clark, Dept of Psychiatry, College of Physicians & Surgeons, Columbia Univ New York, N.Y 10032, USA

Aim of Investigation To compare the responses of 29 Russian and 29 American patients, hospitalized for cancer-related pain, to the Multidimensional Affect and Pain Survey (MAPS) MAPS is a 101 item questionnaire with 30 subclusters and 3 major clusters I Sensory, II Suffenng and III Well-Being. It is based on a dendrogram determined by cluster analysis of similarity judgments to 270 descriptors of the sensory, emotional, motivational and other aspects of pain.

Methods The patients rated the intensity of their sensations and feelings on a scale from 0 (Not at all) to 5 (Very much so)

Results. For the Russians and Americans, respectively, scores on the Superclusters were (p<.05) I Sensory, 2 3 & 1 1,11 Suffering, 2 6 & 1 3, Well-Being, 1.9 & 3 0 Kamofsky scores were 70 & 77 The Russian patients gave higher ratings to various MAPS subclul-sters examples follow I Sensory Pain Extent (containing items such as Spreading, Worsening, Pervasive) p< 001, Intense Pain (Vicious, Nasty, Overwhelming) p< 01, and Autonomic Distress (Disgusting, Nauseating) p< 05, (possibly due to lack of expensive antiemetic medication) II Suffering Physical Illness (Ailing, Suffering) p< 001, and Fear (Alarming, Frantic, Terrified) p< 04 II Well-Being Russian patients had lower scores on Healthy Activities (Active, Vigorous) p< 01 and Positive Affect (Hopeful, Encouraged, Satisfied) p< 001

Conclusions The negative scores of the Russian patients could reflect cultural differences in pessimism/optimism, lower doses of analgesic, psychotropic and/or anti-emetic medications, or perhaps the slightly lower Kamofsky score

Acknowledgment Supported by a grant from the Nathaniel Whar-ton Fund for Research and Education in Brain, Body and Behavior

PAIN THERAPY AND QUALITY OF LIFE IN CHRONIC TUMOR PATIENTS - A REPRESENTATIVE SURGERY

W Pipam, R Likar, D Lakomy, R Krumpholz, H Janig, G Ber-natzky, R Sitti, Dept ofAnaesthesiology, Landeskrankenhaus Kla-genfurt, Austria, Pain Clinic, Univ ofErlangen, Germany

Aim of Investigation. Likar, Bematzky et al/1998 recently surveyed a group of family physicians regarding their prescribing habits with respect to opiates in chronic tumor patients Their survey showed that many physicians have altered their prescribing habits and that much more opiate medication is being prescribed for pain therapy in these patients. At present it is not know whether the affected patients have profited from this development The aim of the present study is to determine through a representative, unbiased survey to what degree the care and quality of life have improved in patients with chronic tumor pain

Methods A random sample of patients (N=7,008) was selected from the tumor registry (total of 25,067 patients) These patients were sent a questionnaire by mail (including an explanatory letter and later a reminder letter) The mailings took place from May to December 1998 in 3 waves The questionnaire included the following aspects Demographic variables, the quality of life, the history of the pain, the pain experience (qualitative, quantitative) an explanation and information, therapeutic modalities and the satisfaction with the pain therapy (side effects) Results: By December 1998 1170 questionnaires were returned Up until this point in time 365 questionnaires have been analysed and evaluated Preliminary results are as follows 1) very little explanation with regards to the diagnosis and the natural history of illness, 2) insufficient explanation with respect to opioids, 3) fear of dependence on the part of patients

Conclusion: The need to provide (with information) with respect diagnosis and therapy is still present and needs to be improved.

PAIN IN A CANCER TREATMENT CENTER: THE PATIENT'S, THE NURSE'S AND THE DOCTOR'S POINT OF VIEW

Pouymayou J. Sue A, Desclaux B*, Caunes N*, Salle F*, Institut Claudius Regaud, 20-24, rue du Pont Saint Pierre 31052 Toulouse Cedex, France

Aim of Investigation: Despite an increase in attention to the treatment of pain in France, the need for changes in patient care is mandatory, especially for patients with cancer. However a lot of local custom and prejudice from both patients and doctors lead to an under assessment and a undermanagement of pain In order to understand the need and expectations of the specific population of the Institut Claudius Regaud before the onset of a multidisciplinar; team against pain, a survey was conducted

Methods Three different kinds of questionnaires were used A bnefpam inventory was addressed to the 1600 patients who came through the Center during a week It used 10 point scale to evaluat pain and tried to distinguish pain inherent to the disease from pain induced by therapeutics The patient point of view on the adequacy of pain management was also demanded A questionnaire was sen) to the 150 nurses from the center The 80 doctors from the Center (surgeons, medical doctors, radiotherapeutics) received also a questionnaire about the significance of pain in their clinical practice

Results Results of this survey will be given The discrepancies between one or another population will be pointed out Conclusion The results of this survey will bring concrete results ti evaluate the state of the art of pain management in the Institut Claudius Regaud in Toulouse It will be useful to build up the policy of the polydisciplinary team against pain

MIDAZOLAM AS AN ANALGESIC IN CANCER PAIN

Jan Prochazka*. (SPON A Prokop) Neurosurgery dept of Masaryk Hospital, 40113, Usti nad Labem, Czech Republic

Aim of Investigation. Conventional analgesic therapy is not sufficient in many cases of cancer pain There are several clinical studies about analgesic effect ofintrathecally administered GABA-agonist midazolam in recent years

Methods From October 1996 to September 1997 in Neurosurgical Dept of the Masaryk Hospital Usti nad Labem we administered midazolam mtrathecally in 17 patients with spine cancer pain - in total 30 administrations Each patient received spmally single dose of 5 mg midazolam dissolved in 3 mL of 5% dextrose We used only 22-gauge spinal needle for mtrathecal injection Results Thirteen patients had metastatic bone diseases, one patien had spinal plasmocytome, in 3 cases in time of administration diagnosis were not known exactly In 2 patients site of disease was i cervical spine, in 6 patients in upper thoracic spine, in 3 patients ir lower thoracic spine and in 6 patients in lumbar spine In time of administration 8 patients had only pain, 9 patients had pain and neurologic deficiency Only 26 administrations in 13 patients were evaluated Pain relief after single dose is shown in Table 1 Total analgesia means previous opioid therapy wasn't necessary, partial analgesia means that patient needs opioids therapy in lower doses

Table 1. Level of analgesia and duration of pain relief
analgesia
up to 5 days
up to 2 weeks
more than 2 weeks
in total
total
5
2
6
13
(50%)
partial
5
1
1
7
(27%)
none
-
-
-
6
(23%)
in total
10
3
7
26
(100%)

Conclusion In cases spine cancer pain mtrathecal administration of midazolam seems to be a useful supplement ofanalgetic treatment Adverse effect in some patients were not relevant Intrathecally administered midazolam has in our experience similar analgetic effect in chronic low back pain

ANESTHESIA PAIN SERVICE CANCER REFERRALS

Elizabeth Roche. Maywin Liu, Leslie DeLaney*, Richard Garcia-Murioz*, Hospital of the Univ of Pennsylvania, Dept of Anesthesia, Philadelphia, PA 19104, St Joseph's Hospital, Dept of Anesthesia, Baltimore, MD 21204, USA

Aim of Investigation Evaluate the usage of anesthesia pain service by physicians who treat cancer patients

Methods In this retrospective review ofinpatient cancer consults, the services, timing, and reasons for referral to the anesthesia pain service were evaluated

Results Eighty cancer mpatient consults were identified between 2/97 and 1/99 The most common referring services were Oncology and General Surgery (Table 1) The number of consults increased towards the end of the reviewed penod Most consults were obtained within 2 weeks of admission Almost all consults were for management of tumor-related pain

Table 1

Referring Service
Number of Referrals
avg time between admission and consult*
Oncology
28
10.5 days
General Surgery
16
14.3 days
Surg Oncology
6
3.6 days
Thoracic Surgery
2
14 days
Neurosurgery
5
2.8 days
Otolaryngology
6
1.8 days
Orthopedics
1
4 days
Plastic Surgery
2
1 day
Gynecology
6
1.6 days
Internal Medicine
7
9.3 days
*Complete dates not available for 8 patients

Conclusion Though many physicians caring for cancer patients appear to be aware of the presence of the anesthesia pain service, they appear to consult anesthesia fairly late Many of the patients presented with histories of significant pain prior to admission However, patients with admitting diagnosis of pain were referred to anesthesia quickly, often with good results. As the anesthesiologist has the ability to improve the scope of pain management for cancer patients, the routine addition of the anesthesiologist in the care of cancer patients, especially for palliative care, should be considered

MANAGEMENT OF CANCER PAIN - A QUESTIONNAIRE SURVEY OF CURRENT PRACTICE IN WEST AFRICA

O.A. Soyannwo. S D Amanor-Boadu*, Dept of Anaesthesia, Univ College Hospital, Ibadan, Nigeria

Aim of Investigation To collect information on current practice in treatment of cancer pain by West African surgeons and oncolo-gists.

Methods. A descriptive study was conducted by administering a structured Questionnaire to 80 Fellows attending the Annual Scientific Conference of the West African College of Surgeons in January 1996

Results: The response rate was 55% by surgeons from 4 countries -Nigeria (32), Ghana (9), Liberia (1) and Sierra-Leone (2) Respondents felt that cancer pain was due to cancer and its treatment (52.3%) or cancer alone and fear of dying (47 7%) Only 9 respondents (20 5%) routinely perform psychological assessment Anti cancer therapy employed by all respondents were surgery, chemotherapy and hormone therapies Radiotherapy was employed in few cases, as facilities were only available in two centers in Nigeria Most (82%) respondents prescribe dihydrocodeine, non-steroidal i anti-inflammatory drugs (73%), pentazocme (46%) or Pethidine ? (42%) for severe pain Parenteral morphine was prescribed by few (18%) while only two respondents had access to oral morphine and Brompton's cocktail Reasons for restricted use ofopioids included problems of availability and anticipated complications

Conclusion The study revealed major deficiencies in the knowledge of respondents concerning cancer pain and its management Inadequate facilities and opioid unavailability have been identified Education on appropriate use and benefits ofopioids is essential in West Africa for better cancer pain management in the next millennium

THE TREATMENT OF BREAST CANCER IN ACCORDANCE WITH ARN THEORY

Elena Trofm, Bucharest Homeopathic Institut, 5 Panselelor St, Bacau 5500, Romania

Methods' ARN is a nbonucleotide of synthesis, a kind of artificial ARN which given after breast surgery to women who suffered of breast cancer with axillary metastasis with insemination gives superior results to the best chemotherapy treatment More than that the well known side effects ofcytosts do not appear It is possible to induce chemically to animals a breast cancer using DMBA

Conclusions The conclusions of the above experiment are the following The experiment shows that a dilution of 9 CH and 15 CH ofADN/ARN gives a significant protection to animals in front of DMPA in the breast cancer It delays the evolution of breast cancer without preventing it In the second model the size and number of tumors are the only objective symptoms and we should need d greater number of animals in order to obtain reliable significant results When we use both radiotherapy and chemotherapy Jammer prefers Korsakov dilutions of 6-12, 30-200 and during the breaks of chemotherapy cures he uses 9 CH and 15 CH Hahnemanien dilution Galvanized ARN and ADN dilutions given to the patients submitted to radiotherapic cure allow remarkable tolerance Small and medium dilutions are preferred because they have to be closer to weight of the patients 9 CH and 15 CH dilutions seem to be more active for a long term treatment

THE OCCURRENCE OF COMPLICATIONS IN CANCER PATIENTS WITH IMPLANTED EPIDURAL CATHETERS

D Tundis. S Datta, S Jam, A Racolm, K Holntz Pain Service, Dept ofAnesthesiology and Critical Care Medicine, Memorial Sloan-Kettermg Cancer Center, NY, NY 10021, USA

Aim of Investigation Patients with intractable cancer pain who have inadequate analgesia and/or intolerable side effects with systemic opioids frequently respond to epidural analgesics Many complications have been reported including: infection, 2-30%, epidural abscess, 0 6-25%, catheter occlusion, 3-12%, pain on injection, 3-36%, mechanical problems, 10-44%, and meningitis, 1-25% Our experience revealed some differences

Methods We reviewed the records of 75 consecutive cases in which the DuPen epidural catheter was implanted All of them received a combination ofopioid and local anesthetic administered as a continuous infusion with the option for patient-controlled boluses

Results Complications resulting in removal of the catheter occurred in eight of the 75 patients (10%) Complications were epidural abscess in 2 patients (2 6%), one of which required a lammectomy, pain on injection of bolus doses due to epidural fi-brosis, 2 (2 6%), spinal hyperalgesia, 2 (2 6%), delirium, 2 (2 6%), and meningitis, I (1 3%) Eleven patients were readmitted for terminal care All others died at home

Conclusions The possibility of serious complications resulting from implanted epidural catheters is always a concern In our series, 89% achieved good pain control with minimum side effects and few complications

VALIDATION OF THE MULTIDIMENSIONAL AFFECT AND PAIN SURVEY (MAPS) IN CANCER PATIENTS

Rachel Tova Wmer*. Dept Psychology, St Johns Univ, W Craw-ford Clark, Mary Louise Keohan*, Ralph N Wharton and Susanne Bennett Clark*, Depts of Psychiatry and Medicine, Oncology Division, College of Physicians and Surgeons, Columbia Univ, New York.NY 10032

Aim of Investigation To validate the MAPS questionnaire MAPS consists of 101 items distributed within 3 Superclusters containing 30 subclusters that assess the sensory, emotional, motivational and other aspects of both pain and suffenng It is based on a dendrogram determined by cluster analysis of 270 descriptors Another goal is to examine the extent to which a rating of "pain" on an intensity scale is actually related to sensory pain factors, and how much to emotional and psychosocial variables

Methods Thirty-one oncology patients (mean Kamofsky score 74 4) responded to MAPS, McGill Pain Questionnaire (MPQ), Profile of Mood States (POMS) and Patient Pain Rating Scale (PPRS) MAPS and PPRS responses were rated on a scale from 0-Not at All to 5-Very Much So

Results' For the 3 MAPS Superclusters the mean values were I Sensory=l 1, II Suffenng=l 1, III Well-Bemg=2 9, PPRS=1 3, Number of Yes responses to MPQ Sensory=6 7/42 items, Af-fect=2 3/14, Evaluative=l 6/5. POMS Depression Scale=46 0, Vigor-Active Scale=49 9 The following correlations demonstrate that the MAPS and MPQ scores agree MAPS I Sensory with MPQ Sensory, r= 64***, and with MPQ Evaluative, r= 58***, MAPS II Suffenng with MPQ Affect, r= 77***, and MPQ Evaluative, r= 61 ***. POMS was correlated as follows Depression Scale with MAPS II Suffenng, r= 67*** and with MPQ Affect, r= 63***, Vigor-Activity Scale with 111 Well-being, r= 51**, and with II Suffenng r=- 48** Kamofsky Scores showed the following associations with MAPS, I Sensory, r=- 40*, II Suffering, r= 46**, and III Well-being, r= 42*, with the MPQ Sensory, r=- 20, Affect r=-.42*, Evaluative, r=-.30 and with the POMS Depression scale r=-.60*** The PPRS correlated with MAPS, 1 Sensory, r= 53** II Suffenng, r= 42* and III Well-Being, r=- 28

Conclusions The MAPS questionnaire yields scores that agree with standard sensory (MPQ) and psychological (POMS) tests and MAPS showed higher correlations with the Kamofsky scores MAPS takes less time, and because there is no separate, and obvious, test of psychological symptomatology, it is less offensive to patients. It is also clear that the pain rating response is not only a sensory measure but is influenced by emotion.

Acknowledgement Supported by the Nathaniel Wharton Fund for Research & Education in Brain, Body & Behavior

GREEK BRIEF PAIN INVENTORY (B.P.I.-G ): VALIDATION AND UTILITY IN CANCER PAIN

Mystakidou K., Mendoza T., Befon S., Tsilica E , Parpa E., Bellos G , Vlahos L., Cleeland C , Pain Relief and Palliative Care Unit, Dept of Radiology, Univ of Athens, Areteion Hospital, Athens Greece, Pain Research Group, Univ of Texas, Andersen Cancer Center, Texas USA, Health Care Center of Koropi, Attiki, Greece

Background: The BnefPam Inventory (BPI) is a pain assessment tool, measunng both pain intensity and pain interference with patient's life. It has been translated and validated in several languages. The purpose of this study was the translation and validation of the BPI in Greek Moreover, we wanted to underline cultural and social differences, if any, on pain interference to patient's life.

Patients and Methods: The translation and validation of the inventory took place at Areteion Hospital The final validation sample consisted of 220 cancer patients (123 males, 97 females, age range 21-87, mean age 61 3) Pnmary cancer locations were lung 25 6%, gastrointestmal tract 25 6%, breast 11 5%, prostate 7.07%, gyne-cological 9 6%, and other 2057% The majonty of the G-BPI papers were completed by the patients themselves Pain management index was also calculated in order to assess the adequacy of pain treatment The actual validation of the G-BPI was made by assessing the reliability (using coefficient alphas) and the validity (by Hierarchical Factor Analysis of oblique Factor)

Results Pain seventy-pain management 147 patients reported severe pain, 48 patients moderate and 22 patients mild pain (mean average pain 6 22) From these patients only 25 were found on strong and 39 on weak opioid treatment, while 118 patients were found on no analgesic treatment at all In agreement with these data is the PMI which was positive only for 11 patients, while 43 patients had PMI =0 and all the others had negative PMI scores Reliability-Validity of the G-BPI Coefficient alphas were 0 849 for the "interference" items and 0 887 for the "seventy" items indicating small measurement error. Additionally, as with other language versions of the BPI, the factor analysis of the G-BPI items results in a two factor solution, that satisfies the criteria ofrepro-ducibility, mterpretability and confirmatory setting

Conclusion In conclusion this study shows the efficacy of the G-BP1 for the assessment of pain severity as well as the pain management in Greece, and therefore its utility on improving the analgesic treatment outcome, in Greek patients

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.209 - 214

   

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