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Anesth Analg 2002 Jul;95(1):229-32, table of contents
Department of Anesthesiology, Chi-Mei Medical Center, Tainan, Taiwan. 400002@mail.chimei.org.tw
Dexamethasone is an effective antiemetic drug, but the efficacy of small-dose dexamethasone 5 mg on the prophylaxis of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy has not been evaluated. We, therefore, evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on PONV in patients undergoing laparoscopic cholecystectomy. Tropisetron and saline served as controls. One-hundred-twenty patients scheduled for laparoscopic cholecystectomy were enrolled in a randomized, double-blinded, placebo-controlled study. At the induction of anesthesia, the Dexamethasone group received IV dexamethasone 5 mg, the Tropisetron group received IV tropisetron 2 mg, and the Placebo group received IV saline. We found that both dexamethasone and tropisetron significantly decreased the following variables: the total incidence of PONV (P < 0.01), more than four vomiting episodes (P < 0.05), and the proportions of patients requiring rescue antiemetics (P < 0.05). The differences between the Dexamethasone and Tropisetron groups were not significant. We conclude that prophylactic IV dexamethasone 5 mg significantly reduces the incidence of PONV in patients undergoing laparoscopic cholecystectomy. At this dose, dexamethasone is as effective as tropisetron 2 mg and is more effective than placebo. IMPLICATIONS: We evaluated the prophylactic effect of small-dose dexamethasone (5 mg) on postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy. Tropisetron (2 mg) and saline served as controls. We found that dexamethasone 5 mg (IV) significantly reduced the incidence of PONV in these patients, and, at this dose, dexamethasone was as effective as tropisetron and was more effective than placebo.
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PMID: 12088975, UI: 22083401
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Anesth Analg 2002 Jul;95(1):169-76
Department of Anesthesiology and Intensive Care, Karolinska Hospital, Stockholm, Sweden. connail@eircom.net
PMID: 12088963, UI: 22083389
Anesth Analg 2002 Jul;95(1):158-62, table of contents
Department of Anaesthesia, Critical Care, and Pain Management, University Hospitals of Leicester, NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK. anae@le.ac.uk
The objective of our study was to see if incisional and intraperitoneal bupivacaine with epinephrine produces analgesia after total abdominal hysterectomy. Forty-six ASA physical status I and II patients received a standardized anesthetic, patient-controlled analgesia (PCA) morphine, and rectal paracetamol 1 g every 6 h. Patients were randomized to receive 50 mL of bupivacaine 0.25% with epinephrine 5 microg/mL or 50 mL of normal saline. Thirty milliliters and 20 mL of treatment solution were administered into the peritoneum and incision, respectively, before wound closure. Seventeen and 16 patients in the Placebo and Bupivacaine groups, respectively, completed the study. The reasons for withdrawal were PCA malfunction, PCA discontinued too early, nausea, chest infection, intraabdominal drain insertion, and protocol violation. There were no significant differences between the Bupivacaine and Placebo groups in age, height, weight, or duration of surgery. Pain on movement was significantly more intense in the Placebo group than in the Bupivacaine group on awakening. Morphine consumption (interquartile range) over 24 h was 62 mg (53-85 mg) in the Placebo group compared with 44 mg (33-56 mg) in the Bupivacaine group (P < 0.01). This significant difference was attributable to the larger morphine consumption in the Placebo group in the first 4 postoperative h. We conclude that a combination of intraperitoneal and incisional bupivacaine with epinephrine provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy. IMPLICATIONS: A combination of intraperitoneal and incisional bupivacaine with epinephrine may be recommended because it provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.
PMID: 12088961, UI: 22083387
Anesth Analg 2002 Jul;95(1):103-8, table of contents
Department of Anesthesiology, Hopital Ambroise Pare, Assistance Publique Hopitaux de Paris, 9 Avenue Charles de Gaulle, Boulogne-Billancourt 92100, France.
Relative large-dose intraoperative remifentanil could lead to the need for more postoperative analgesics. Intraoperative N-methyl-D-aspartate receptor antagonists, such as ketamine, decrease postoperative opioid use. We therefore tested the hypothesis that intraoperative small-dose ketamine improves postoperative analgesia after major abdominal surgery with remifentanil-based anesthesia. Fifty patients undergoing abdominal surgery under remifentanil-based anesthesia were randomly assigned to intraoperative ketamine or saline (control) supplementation. The initial ketamine dose of 0.15 mg/kg was followed by 2 microg. kg(-1). min(-1). In both groups, desflurane was kept constant at 0.5 minimum alveolar anesthetic concentration without N(2)O, and a remifentanil infusion was titrated to autonomic responses. All patients were given 0.15 mg/kg of morphine 30 min before the end of surgery. Pain scores and morphine consumption were recorded for 24 postoperative h. Less of the remifentanil was required in the Ketamine than in the Control group (P < 0.01). Pain scores were significantly larger in the Control group during the first 15 postoperative min but were subsequently similar in the two groups. The Ketamine patients required postoperative morphine later (P < 0.01) and received less morphine during the first 24 postoperative h: 46 mg (interquartile range, 34-58 mg) versus 69 mg (interquartile range, 41-87 mg, P < 0.01). No psychotomimetic symptoms were noted in either group. In conclusion, supplementing remifentanil-based anesthesia with small-dose ketamine decreases intraoperative remifentanil use and postoperative morphine consumption without increasing the incidence of side effects. Thus, intraoperative small-dose ketamine may be a useful adjuvant to intraoperative remifentanil. IMPLICATIONS: Supplementing remifentanil-based anesthesia with small-dose ketamine decreased intraoperative remifentanil use and postoperative morphine consumption. These data demonstrate that N-methyl-D-aspartate antagonists, such as ketamine, can be a useful adjuvant to intraoperative remifentanil.
PMID: 12088951, UI: 22083377
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Ann Fr Anesth Reanim 2002 Apr;21(4):315-35
Inserm U-161, 2, rue d'Alesia, 75014 Paris, France.
OBJECTIVE: To bring together the most recent data concerning the physiology of nociceptors at a time when there has been significant progress in the understanding of these. DATA SOURCES: References were obtained from computerised bibliographic data banks (Medline and others) and the authors' personal documents. DATA SYNTHESIS: Nociceptive impulses are generated at the periphery in unmyelinated fibres called nociceptors, the responses of which depend on the tissue environment. Numerous mediators can activate, sensitise or "wake up" nociceptor: kinins (bradykinin, kallidin and their metabolites), pro-inflammatory cytokines (TNF alpha, IL-6, IL-1 beta, IL-8), anti-inflammatory cytokines (IL-4, IL-6, IL-10, IL-12, IL-13), prostanoids (PGE2, PGI2), lipo-oxygenases (leucotrienes such LTB4 or 15-HETE), the "central mediators of the immune response" (NF-kappa B), growth factors such as neurotrophins (NGF, BDNF, NT-3 and NT-4/5), peptides (substance P, CGRP, Neurokinin A), nitric oxide, histamine, serotonin, proteases, excitatory amino acids, adrenergic amines and opioids. The release of neuromediators by primary afferent fibres in the spinal cord may be summarised by successively considering calcium channels, presynaptic receptors, excitatory amino acids and peptides. CONCLUSION: Sensitisation phenomena are not exclusively peripheral but also central in origin and these are interlinked.
PMID: 12033102, UI: 22029859
Ann Fr Anesth Reanim 2002 Apr;21(4):276-94
Service d'anesthesie-reanimation, hopital Tenon, 4, rue de la Chine, 75970 Paris, France.
OBJECTIVES: This study presents a tool including survey questionnaires and a specific data-processing software for the data processing, allowing health care providers to assess the quality of postoperative pain management in surgical wards. STUDY DESIGN: Descriptive study. METHODS: A committee including anesthesiologists, nurses and epidemiologists had elaborated and tested three survey questionnaires to assess patients, nurses and medical staff satisfaction respectively. Specific data processing software was issued out of the final questionnaires. It allowed a quick analysis of items possibly, explaining inadequate postoperative pain management. After this adjustment, this tool was used in three different surgical wards, named A, B, C. RESULTS: The rate of answer (of investigated persons) being over 50%, data resulting from the survey performed in the surgical wards A and B were considered valid. The items which could explain insufficient pain relief were classified into 4 levels: patients assertion (ex: more than 50% of patients experienced persistent postoperative pain); practices evaluation (ex: 42 to 72% health care providers declared being aware of analgesic procedures); behavior's evaluation (ex: 19 to 34% of health care providers considered persistent postoperative pain to be useful for monitoring); and surgical wards potential (ex: 21 to 61% of health care providers took a specific course on pain management). Pros and cons of this tool were carefully examined and subsequent strategies defined. CONCLUSIONS: This survey's device should allow health care providers to assess the quality of postoperative pain management in surgical wards. Its validation is currently developed to improve its use, and keep the most performing indicators, showing an adequate postoperative pain management.
PMID: 12033096, UI: 22029853
Ann Fr Anesth Reanim 2002 Apr;21(4):263-70
Service d'anesthesie-reanimation chirurgicale 2, centre hospitalier et universitaire de Ponchaillou, universite de Rennes I, 35033 Rennes, France.
INTRODUCTION: Injection pain caused by propofol is an important disadvantage, especially in children, incompletely reduced by adding lidocaine intravenously. Nitrous oxide's analgesic effects, well known, have never been evaluated on pain due to propofol. OBJECTIVE: To compare the effects of nitrous oxide with lidocaine on pain on injection caused by propofol in children. STUDY DESIGN: Double blind, randomised, prospective study. PATIENTS AND METHODS: 48 children aged more than 5 were randomly allocated to one of the 2 groups: N2O group, breathed 50% N2O + 50% O2 than received propofol only and Lido group breathed 100% O2 and received a mixture of propofol with lidocaine. The possible pain was scored during injection by a behavioural scale and once again in the recovery room by the child himself with a VAS. RESULTS: There was no significant difference in behavioural pain scores among the 2 groups; pain was assessed as being moderate or severe in 6/24 patients in N2O group and 10/24 in Lido group (behavioural scores > 1). Significantly more children in the N2O group had low VAS scores compared with the Lido group (no child/24 scored a VAS > 4 and 7/23 in the Lido group) demonstrating that N2O amnesic effects would omit the memory of pain caused by propofol. CONCLUSION: The use of nitrous oxide is an easy, cheap and efficient method to reduce the incidence of pain injection of propofol and his amnesic effects can provide real advantages in paediatric anaesthesia.
PMID: 12033094, UI: 22029851
Cephalalgia 2002 Jul;22(6):453-461
Kings Headache Service, Kings College Hospital, Denmark Hill, London SE5 9RS, UK, Hopital saint-Antoine-Service de Neurologie, Paris, France, Hospital General de Valencia, Valencia, Spain, and Laboratorios Almirall SA, Madrid, Spain.
[Record supplied by publisher]
Almotriptan is a novel and specific serotonin 5-HT1B/1D agonist for the acute treatment of migraine. This randomized, single-dose, double-blind, multicentre, study assessed the efficacy and safety of oral almotriptan (12.5 mg and 25 mg) in patients with migraine, and compared it with the standard treatment (sumatriptan 100 mg) and placebo. A total of 668 patients treated one migraine attack of moderate or severe intensity with study medication. The primary efficacy assessment was migraine pain relief, improvement from severe or moderate pain to mild or no pain, at 2 h after treatment. Response rates, stratified for variation in baseline pain levels, for both almotriptan doses were equivalent to sumatriptan and significantly better than placebo. Other efficacy assessments confirmed the equivalence of the almotriptan groups with the sumatriptan group. Almotriptan 12.5 mg was as well tolerated as placebo (P=0.493) and significantly better tolerated than sumatriptan (P<0.001), in terms of the overall incidence of adverse events. There was no statistically significant difference in the incidence of adverse events between almotriptan 25 mg and sumatriptan 100 mg (P=0.376). The results from this large clinical study indicate that the new, specific 5-HT1B/1D agonist, almotriptan, is an effective and well-tolerated treatment for migraine pain.
PMID: 12133045
Geriatrics 2002 Jul;57(7):20
University of Arizona Health Sciences Center, Tucson, USA.
PMID: 12134460, UI: 22130504
N Engl J Med 2002 Jul 11;347(2):81-8
Houston Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX 77030, USA.
BACKGROUND: Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee. METHODS: A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated debridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores--three on scales for pain and two on scales for function--and one objective test of walking and stair climbing. A total of 165 patients completed the trial. RESULTS: At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (+/-SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and debridement groups: 48.9+/-21.9, 54.8+/-19.8, and 51.7+/-22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and debridement) and 51.6+/-23.7, 53.7+/-23.7, and 51.4+/-23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference. CONCLUSIONS: In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.
PMID: 12110735, UI: 22107028
Reg Anesth Pain Med 2002 May-Jun;27(3):336
PMID: 12016621, UI: 22012112
Reg Anesth Pain Med 2002 May-Jun;27(3):319-21
Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
BACKGROUND AND OBJECTIVES: Methadone is an inexpensive and highly effective analgesic when titrated appropriately. Its equianalgesic ratio with other opioids is variable, however. We present a case of conversion from high-dose intrathecal (IT) morphine to oral methadone. CASE REPORT: A 37-year-old man was admitted to the orthopedic service due to increased lower back pain. He had a history of recurrent L5 plasmacytoma, an L5 corpectomy, and L3-S1 fusion with instrumentation. An implanted neuraxial drug delivery device had been placed at another institution for back pain. Evaluation suggested infection involving the hardware. The patient underwent hardware removal, debridement of osteomyelitis, and removal of the IT catheter. The patient's analgesia was converted from IT to intravenous morphine and then to oral methadone. CONCLUSIONS: The conversion from high-dose IT morphine to oral methadone has not been previously described. The case presents higher IT morphine to oral methadone conversion ratio than might be expected based upon conventionally used equianalgesic tables.
PMID: 12016609, UI: 22012100
Reg Anesth Pain Med 2002 May-Jun;27(3):316-8
Department of Anaesthesia and Pain Management, St Vincent's Hospital, Dublin, Ireland. mduncan32@hotmail.com
BACKGROUND AND OBJECTIVES: Sternal fracture pain is severe and is difficult to alleviate due to the forces acting on the chest wall during respiration. We describe a continuous infusion regional analgesic technique for pain due to sternal fracture. CASE REPORT: A 47-year-old woman presented with a spontaneous sternal fracture, precluding effective coughing. Diclofenac and increasing doses of opioids did not give adequate pain relief and led to opioid toxicity. Two brief periods of analgesia were achieved with deep subcutaneous infiltration of bupivacaine. An epidural catheter was positioned periosteally, and an infusion of bupivacaine was commenced at 5 mL/h, achieving long-lasting analgesia. The bupivacaine concentration was reduced in a stepwise fashion from 0.5% to 0.25% and was changed to levobupivacaine after 3 days. Adding morphine (5 mg/60 mL levobupivicaine) permitted a reduction in infusion rate. The catheter was removed after 14 days because a local infection developed that resolved uneventfully with antibiotic therapy. CONCLUSIONS: Continuous infusion of local anesthetic and opioid to a sternal fracture site using a periosteally positioned catheter led to successful analgesia and hence improved respiratory function. Clinicians should consider placing a periosteal catheter when pain associated with sternal fracture cannot be adequately controlled with conventional methods.
PMID: 12016608, UI: 22012099
Reg Anesth Pain Med 2002 May-Jun;27(3):309-12
Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama 35294-0007, USA. tim.ness@ccc.uab.edu
Topically applied single or multiagent analgesics compounded by specialty pharmacies are utilized by an unknown number of pain clinicians to unknown effect. To assess the use and perceived efficacy of these agents, an e-mail survey of members of the American Society of Regional Anesthesia and Pain Medicine was performed. Response rate was low, but identified use of compounded topical agents throughout the United States. Of the 120 clinicians responding, 27% (n = 32) reported that they prescribed compounded topical analgesics containing 1 to 5 agents (mean + SEM; 2.6 +/- 0.2) in their practice 3.5 +/- 0.6 times per month. Use of 36 different agents of varying concentrations was reported. These clinicians perceived that 43% +/- 4% of treated patients responded favorably to the topical agents with an average of 47% +/- 3% pain relief and few side effects. Despite favorable reports of benefit, most clinicians perceived use of such compounded agents in their regions to generally be "little or none."
PMID: 12016606, UI: 22012097
Reg Anesth Pain Med 2002 May-Jun;27(3):306-8
Department of Anesthesiology and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech Republic. pafkam@seznam.cz
PMID: 12016605, UI: 22012096
Reg Anesth Pain Med 2002 May-Jun;27(3):277-83
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA. tgrabow@jhmi.edu
BACKGROUND AND OBJECTIVES: High neuraxial drug infusion has been advocated for the treatment of intractable cranial and facial pain in humans. Currently, parallel animal models have not been characterized to support this methodology. We combined an accepted animal model of pain of cranial origin with a novel technique of cervico-medullary drug delivery to determine the antinociceptive potential of gabapentin. Gabapentin was chosen because of its reported efficacy in a wide array of complex cranial pain syndromes. METHODS: Male Wistar rats were implanted with intrathecal catheters that were advanced cephalad through a lumbar guide cannula to terminate in the high cervical spinal cord (C1-C4). Antinociception was assessed by the orofacial formalin test. Vehicle or gabapentin (3, 10, 30, 100 microg) was injected intrathecally followed 10 minutes later by injection of 2.5% formalin solution into the vibrissal pad. Motor assessment was evaluated in a separate group of animals. RESULTS: Intrathecal gabapentin (10, 30, 100 microg) produced a dose-dependent decrease in the second phase of the behavioral response to formalin (P <.05). First-phase responses were unaffected by all doses of gabapentin. The ED50 (95% confidence limit) value for the second phase was 8.27 microg (3.50 to 14.5). No overt motor dysfunction or behavioral impairment was observed. CONCLUSIONS: Gabapentin produced dose-dependent antinociception in the second phase of the orofacial formalin test in the rat after injection into the cervico-medullary cerebrospinal fluid. This animal model may be useful to assess analgesics designed for parallel clinical application in humans for the treatment of intractable head and neck pain that is refractory to conventional modalities.
PMID: 12016601, UI: 22012092
Reg Anesth Pain Med 2002 May-Jun;27(3):254-60
Acute Pain Service, Department of Anesthesiology, Hvidovre University Hospital, Copenhagen, Denmark. madswerner@medscape.com
BACKGROUND AND OBJECTIVES: Glucocorticoids are well-known adjuvant analgesics in certain chronic pain states. There is, however, a paucity of data on their analgesic efficacy in acute pain. Therefore, the aim of the study was to examine the analgesic effects of dexamethasone in a validated burn model of acute inflammatory pain in humans. METHODS: Twenty-two volunteers were investigated in a double-blind, randomized, placebo-controlled cross-over study. Intravenous dexamethasone 8 mg or placebo was administered on 2 separate study days. Two hours after drug administration, a first-degree burn injury was produced on the medial aspect of the nondominant calf (12.5 cm2, 47 degrees C for 7 minutes). Quantitative sensory testing included pain ratings to thermal and mechanical stimuli (visual analog scale [VAS]), assessments of thermal and mechanical detection thresholds, and areas of allodynia and secondary hyperalgesia. RESULTS: The burn injury induced significant increases in erythema (P <.0001) and hyperalgesia (P <.001) in both groups. Pain ratings and development of tactile allodynia during the burn did not differ between dexamethasone and placebo treatments (P >.6). There were no significant differences between treatments in regard to skin erythema (P >.8), thermal or mechanical thresholds (P >.2), thermal or mechanical pain response (P >.2), or mechanical secondary hyperalgesia (P >.2). Dexamethasone had no analgesic effects in normal skin. CONCLUSIONS: The study indicates that systemic administration of dexamethasone 2 hours before a burn injury does not reduce the inflammatory-mediated changes in quantitative sensory thresholds, pain perception, or skin erythema in humans.
PMID: 12016598, UI: 22012089
Reg Anesth Pain Med 2002 May-Jun;27(3):249-53
Department of Anesthesiology, Heinrich-Heine-University, Duesseldorf, Germany. holthusen@med.uni-duesseldorf.de
BACKGROUND AND OBJECTIVES: Preemptive analgesia often failed in the clinical arena because application of a single intravenously applied drug may not prevent nociceptive input and spinal pain processing sufficiently. We therefore used an intravenous (IV), multireceptor approach and tested the preemptive analgesic effect of the antinociceptive drugs morphine, ketamine, and clonidine given before or immediately after surgery. METHODS: A double-blind, randomized, prospective study was performed in 30 patients undergoing transperitoneal tumor nephrectomy (via median laparotomy). Standard general anesthesia procedure without opioids was used. After induction, patients were randomly allocated to receive 150 microg x kg(-1) of morphine, 150 microg x kg(-1) of ketamine, and 5 microg x kg(-1) of clonidine intravenously via a motor-driven pump within 15 minutes, either before or immediately after surgery. Patient-controlled analgesia (PCA) with the opioid piritramide (IV) was used for postoperative analgesia. Postoperative pain at rest and during induced cough was quantified by analgesic requirement and pain scores (visual analog scale [VAS]) within 48 hours. RESULTS: There was no significant difference in analgesic requirement of piritramide and pain scores at rest or during induced cough. CONCLUSIONS: In contrast to encouraging observations on the combination of antinociceptive drugs, the multireceptor approach tested here failed to exert a clinically relevant effect.
PMID: 12016597, UI: 22012088
Reg Anesth Pain Med 2002 May-Jun;27(3):242-4
PMID: 12016595, UI: 22012086
Support Care Cancer 2002 May;10(4):337-42
The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Taussig Cancer Center, The Cleveland Clinic Foundation, 9500 Euclid Avenue, M76, Cleveland, OH 44195, USA.
This prospective study of consecutive patients describes the palliative medicine consult service in a tertiary level cancer center and its impact on patient care. All inpatients/outpatients referred to the Palliative Medicine Program in a 4-month period were enrolled. Data were collected at the initial consultation using standardized forms with spaces for: reason for the consultation, referring service, demographics and history, ECOG performance status, symptoms, prognosis and diagnostic tests, treatment, and care plan. In all, 240 patients were seen: 79% were referred for symptom management; 53% were referred from medical oncology; and 50% were women. Median patient age was 67 years (range 18-96). Median performance status was 2 (1-4). Most (84%) of the patients had cancer. The cancer sites were: lung in 26% of cases, colorectal in 8%, and breast in 7%. Inpatients accounted for 53% and outpatients, for 47% of the study population. The median number of symptoms per patient was 13 (2-30). The estimated survival was <2 weeks in 15%, 2-8 weeks in 38%, 2-6 months in 37%, and >6 months in 10%. The patients' goals were: improve symptoms for 84%, return home for 55%, and no further admissions for 5%. The support systems named by patients were: family in 89%, friends in 13%, and the community in 5%. Hospice care was discussed at the consultation with 38% of the patients, would have been inappropriate for 31%, was not discussed with 22%, and had been discussed before with 9%. In response to questions about psychosocial care, a caregiver was identified by 78%, a spokesperson by 75%, and durable power of attorney was referred to by 21%. The DNR status was discussed on consult by 57%, had already been discussed with 30%, and was not discussed with 13%. Plan of care foresaw outpatient follow-up for 40%, inpatient follow-up for 32%, and transfer to palliative medicine for 27%. In 39% of cases the consults were considered late referrals. New medications suggested were opioids for 46% of patients, antiemetics for 28%, a bowel regimen for 24%, steroids for 15%, and others for 51%. (1) Palliative medicine consultation involves common complex medical, psychological, and social problems. (2) Complex symptomatology in this population is confirmed. (3) Multiple interventions were suggested even at the initial consultation. (4) Important issues such as DNR (do not resuscitate) status, support system, treatment goals, and eligibility for hospice care had often not been addressed.
PMID: 12029434, UI: 22025745
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