A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project

BACKGROUND

Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative's opioid guidelines project.

OBJECTIVE

The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines.

SEARCH STRATEGY

The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals.

SELECTION CRITERIA

Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded.

DATA COLLECTION AND ANALYSIS

This is a narrative systematic review and no meta-analysis was performed. The Grading of RECOMMENDATIONS Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines.

MAIN RESULTS

Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil.

CONCLUSIONS

All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids.

RECOMMENDATIONS

RECOMMENDATIONS regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.

Safety in magnetic resonance units: an update

The number of anaesthetists who are involved in magnetic resonance (MR) units is increasing. Magnetic resonance systems are becoming more powerful and interventional procedures are now possible. This paper updates information relating to safety terminology, occupational exposure, reactions to gadolinium-based contrast agents and the risk of nephrogenic systemic fibrosis. Magnetic resonance examinations of patients with pacemakers are still generally contra-indicated but have been carried out in specialist centres under strictly controlled conditions. As availability of MR increases, so the education of anaesthetists, who are occasionally required to provide a service, must be considered.

Anaesthesia in MR units was first described in the 1980s. Guidelines on the provision of anaesthetic services in MR units were published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2002 [1]. Since then, the number of hospitals with MR units, and hence the number of patients requiring anaesthesia for MR, has increased. While the issues relating to setting up anaesthetic services in MR have not changed, there have been a number of developments that warrant this update:

Safety terminology and guidelines have changed.

MR systems utilise higher magnetic-field strengths and more open designs are available.

Interventional and intra-operative MR are now routine in some centres.

Mobile MR scanners are increasingly used to reduce waiting lists.

Although still generally contra-indicated, some patients with pacemakers have been scanned under strictly controlled conditions in specialist centres.

‘MR safe’ medical implants are now being produced.

New equipment is now available for use in MR.

Out-of-hours availability of MR investigations has increased.

Reports of allergic reactions to MR contrast media have increased.

Gadolinium based contrast agents (Gd-CAs) are associated with a varying degree of risk of nephrogenic systemic fibrosis in patients with impaired renal function.

Cortisol response to a psychosocial stressor in schizophrenia: blunted, delayed, or normal?

BACKGROUND

Patients with schizophrenia may differ from healthy controls by having dysregulated physiological responses to stress. Our objective was to determine the extent to which cortisol reaction can discriminate between controls and schizophrenia patients while controlling for symptom severity, personality, body mass index (BMI) and smoking.

METHOD

30 chronic schizophrenia patients and 30 matched controls underwent a modified version of the Trier Social Stress Test (TSST), consisting of public speaking and mental arithmetic. Heart rate, blood pressure, and salivary cortisol were measured repeatedly throughout the TSST. In addition, participants completed the NEO Personality Inventory (NEO-FFI), and were interviewed with the Brief Psychiatric Rating Scale (BPRS).

RESULTS

Both groups had a significant increase in heart rate and mean arterial pressure following the TSST. Results of a logistic regression suggests that patients can be discriminated from controls with a smaller change in cortisol between baseline and 15 min post-TSST, controlling for BMI and severity of positive symptoms. There was a trend for lower overall cortisol secretion in patients.

CONCLUSIONS

Despite demonstrable effects of the stressor on cardiac measures, schizophrenia patients tend to have smaller acute cortisol reaction to psychosocial stress. The significance of this conclusion for vulnerability-stress models of schizophrenia is discussed.

Signs and symptoms in the pre-psychotic phase: description and implications for diagnostic trajectories

BACKGROUND

Few studies have examined the underlying factor structure of signs and symptoms occurring before the first psychotic episode. Our objective was to determine whether factors derived from early signs and symptoms are differentially associated with non-affective versus affective psychosis.

METHOD

A principal components factor analysis was performed on early signs and symptoms reported by 128 individuals with first-episode psychosis. Factor scores were examined for their associations with duration of untreated illness, drug abuse prior to onset of psychosis, and diagnosis (schizophrenia versus affective psychosis).

RESULTS

Of the 27 early signs and symptoms reported by patients, depression and anxiety were the most frequent. Five factors were identified based on these early signs and symptoms: depression, disorganization/mania, positive symptoms, negative symptoms and social withdrawal. Longer duration of untreated illness was associated with higher levels of depression and social withdrawal. Individuals with a history of drug abuse prior to the onset of psychosis scored higher on pre-psychotic depression and negative symptoms. The two mood-related factors, depression and disorganization/mania, distinguished the eventual first-episode diagnosis of affective psychosis from schizophrenia. Individuals with affective psychosis were also more likely to have a 'mood-related' sign and symptom as their first psychiatric change than individuals later diagnosed with schizophrenia.

CONCLUSIONS

Factors derived from early signs and symptoms reported by a full diagnostic spectrum sample of psychosis can have implications for future diagnostic trajectories. The findings are a step forward in the process of understanding and characterizing clinically important phenomena to be observed prior to the onset of psychosis.

Anterior cerebral artery emboli in combined intravenous and intra-arterial rtPA treatment of acute ischemic stroke in the IMS I and II trials

BACKGROUND AND PURPOSE

Anterior cerebral artery (ACA) emboli may occur before or during fibrinolytic revascularization of middle cerebral artery (MCA) and internal carotid artery (ICA) T occlusions. We sought to determine the incidence and effect of baseline and new embolic ACA occlusions in the Interventional Management of Stroke (IMS) studies.

MATERIALS AND METHODS

Case report forms, pretreatment and posttreatment arteriograms, and CTs from 142 subjects entered into IMS I & II were reviewed to identify subjects with baseline ACA occlusion, new ACA emboli occurring during fibrinolysis, subsequent CT-demonstrated infarction in the ACA distribution, and to evaluate global and lower extremity motor clinical outcome.

RESULTS

During M1/M2 thrombolysis procedures, new ACA embolus occurred in 1 of 60 (1.7%) subjects. Baseline distal emboli were identified in 3 of 20 (15%) T occlusions before intra-arterial (IA) treatment, and new posttreatment distal ACA emboli were identified in 3 subjects. At 24 hours, 8 (32%) T occlusions demonstrated CT-ACA infarct, typically of small volume. Infarcts were less common following sonography microcatheter-assisted thrombolysis compared with standard microcatheter thrombolysis (P = .05). Lower extremity weakness was present in 9 of 10 subjects with ACA embolus/infarct at 24 hours. The modified Rankin 0 to 2 outcomes were achieved in 4 of 25 (16%) subjects with T occlusion overall, but in 0 of 10 subjects with distal ACA emboli or ACA CT infarcts (P = .07).

CONCLUSIONS

With IV/IA recombinant tissue plasminogen activator treatment for MCA emboli, new ACA emboli are uncommon events. Distal ACA emboli during T-occlusion thrombolysis are not uncommon, typically lead to small ACA-distribution infarcts, and may limit neurologic recovery.

Measuring children's participation in recreation and leisure activities: construct validation of the CAPE and PAC

There is a need for psychometrically sound measures of children's participation in recreation and leisure activities, for both clinical and research purposes. This paper provides information about the construct validity of the Children's Assessment of Participation and Enjoyment (CAPE) and its companion measure, Preferences for Activities of Children (PAC). These measures are appropriate for children and youth with and without disabilities between the ages of 6 and 21 years. They provide information about six dimensions of participation (i.e. diversity, intensity, where, with whom, enjoyment and preference) and two categories of recreation and leisure activities: (i) formal and informal activities; and (ii) five types of activities (recreational, active physical, social, skill-based and self-improvement). This paper presents information about the performance of the CAPE and PAC activity type scores using data from a study involving 427 children with physical disabilities between the ages of 6 and 15 years. Intensity, enjoyment and preference scores were significantly correlated with environmental, family and child variables, in expected ways. Predictions also were supported with respect to differences in mean scores for boys vs. girls, and children in various age groups. The information substantiates the construct validity of the measures. The clinical and research utility of the measures are discussed.