Management of cancer-related fatigue in Taiwan: an evidence-based consensus for screening, assessment and treatment

BACKGROUND

Cancer-related fatigue is one of the most common and persistent issues experienced by cancer patients. Cancer-related fatigue is a distinct form of fatigue that is subjective, long-lasting and unalleviated by rest or sleep. Studies have shown that almost all cancer patients experience severe fatigue that disrupts the quality of life and physical function, but cancer-related fatigue remains under-addressed in clinical care, and only about half of all patients receive treatment.

METHODS

To increase the awareness of cancer-related fatigue and improve current management, the Taiwan Society of Cancer Palliative Medicine and the Taiwan Oncology Nursing Society convened a consensus committee to develop recommendations for the screening, assessment and treatment of cancer-related fatigue.

RESULTS

Thirteen consensus recommendations were subsequently developed based on the best available evidence and the clinical experience of committee members.

CONCLUSIONS

These recommendations are expected to facilitate the standardization of cancer-related fatigue management across Taiwan and may also serve as a reference for other clinicians.

The treatment of Parkinson's disease in older people

Parkinson's disease is characterised by a variable combination of tremor, rigidity, bradykinesia and impaired righting reflexes. The cumulative life-time risk is one in 40. Levodopa remains the single most effective treatment in older patients, and the minimum dose to achieve maximum functional benefit should be employed. When fluctuations occur, controlled release preparations and selegiline can improve function. Oral dopamine agonists have a role but the combined side effect profile with levodopa should be monitored. COMT inhibitors have recently become available. Subcutaneous apomorphine can be helpful when "on-off" phenomena are marked. The concept of neuroprotection continues to be debated. Surgery is an option for fitter older people but neurotransplantation remains essentially a research tool.

Bacteraemia in the elderly

The aims of the study were to describe community-acquired and nosocomial bacteraemia in elderly patients and to determine the factors associated with increased mortality in these patients attending a tertiary hospital in Singapore. A consecutive series of 191 patients aged more than 60 years of age admitted in 1995 was studied retrospectively. All of them had positive blood culture results obtained from the Department of Pathology and the case notes were reviewed and entered into a standard clinical protocol. They were analysed for age, sex, place of origin, race, sites of infection, clinical parameters and bacteriology. The mean age of the study population was 75 years (SD = 8.9 years). Bacteraemia was acquired from the community in 57.5% of patients, 33% was nosocomial in origin and 9.5% acquired it in chronic long term care facilities. The common organisms cultured in community-acquired infections were Escherichia coli (26.1%), Klebsiella species (25.4%), Streptococcus species (11.1%), methicillin sensitive Staphylococcus aureus (7.6%) and Proteus mirabilis (4.8%). The common organisms cultured in nosocomial infections were Klebsiella species (19.8%), Enterobacter species (14.6%), E. coli (11.8%), Acinetobacter baumanii (9.2%), methicillin sensitive Staphylococcus aureus (7.9%) and methicillin-resistant Staphylococcus aureus (7.9%). Whilst most cases of bacteraemia were single organism cultures, 13.5% were polymicrobial. The common sources of bacteraemia were chest (27.5%), urinary tract (24.5%), skin (12.5), hepatic (8.8%), gut (4.3%), cardiovascular system (1%) and others (3.6%). In 12.5% of cases, the sources were multiple and in 5.3% of cases, the source could not be identified. Twenty-one per cent of patients with bacteraemia died. The following factors were associated with increased mortality rate: older age (median age of those that died was 78.5 years compared to survivors with a median age of 73 years, P = 0.011), patient's place of origin (patients in nursing home at higher risk of death, P = 0.04), patient's mobility status (immobile patients at higher risk, P = 0.00297), source of bacteraemia--respiratory infection at increased risk of death (P = 0.00009) but urinary tract infection had a better survival rate (P = 0.03935) and multiple sites of infection (patients with multiple sites of infection had higher risk, P = 0.00897). Methicillin-sensitive Staphylococcus aureus bacteraemia was associated with a mortality rate of 35.3%, followed by Klebsiella species 28.6%, Pseudomonas aeruginosa 28.6%, methicillin-resistant Staphylococcus aureus 25%, Proteus mirabilis 25% and E. coli 19.1%. Important clinical parameters which indicated a poor clinical outcome were: high pulse rate, hypotension, increased respiratory rate, low total white cell count, coagulopathy, hypoalbuminaemia and increased creatinine level.