Current opinion in supportive and palliative care
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Curr Opin Support Palliat Care · Jun 2014
ReviewDescending pain modulation and chronification of pain.
Chronic pain is an important public health problem that negatively impacts quality of life of affected individuals and exacts an enormous socio-economic cost. Currently available therapeutics provide inadequate management of pain in many patients. Acute pain states generally resolve in most patients. However, for reasons that are poorly understood, in some individuals, acute pain can transform to a chronic state. Our understanding of the risk factors that underlie the development of chronic pain is limited. Recent studies have suggested an important contribution of dysfunction in descending pain modulatory circuits to pain 'chronification'. Human studies provide insights into possible endogenous and exogenous factors that may promote the conversion of pain into a chronic condition. ⋯ Preclinical studies coupled with clinical pharmacologic and neuroimaging investigations have advanced our understanding of brain circuits that modulate pain. Descending pain facilitatory and inhibitory circuits arising ultimately in the brainstem provide mechanisms that can be engaged to promote or protect against pain 'chronification'. These systems interact with higher centres, thus providing a means through which exogenous factors can influence the risk of pain chronification. A greater understanding of the role of descending pain modulation can lead to novel therapeutic directions aimed at normalizing aberrant processes that can lead to chronic pain.
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To review how common cancers such as breast, lung, and prostate cancers drive significant and frequently life-altering pain when the cells metastasize to bones. ⋯ There is both a nociceptive and neuropathic component of bone cancer pain. In bone cancer pain, there is frequently a continual afferent drive of sensory nerve fibers that induces a peripheral and central sensitization. These mechanistic insights have begun to lead to advances in not only how we understand bone cancer pain but to the development of new therapies to treat bone cancer pain.
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With the majority of deaths from cancer because of their metastases, strategies to reduce this from occurring are at the forefront of treatment. It has been hypothesized that morphine may result in an increase in cancer metastases, following many in-vitro and animal studies, but the evidence from human retrospective data is inconclusive. This article will explore the possible mechanisms by which opioids can impact on the natural history of the cancer cell and whether they are likely to be harmful in individuals with cancer. ⋯ The role opioids play in the development of cancer metastasis and recurrence is far from clear and appears to differ depending on the cancer cell type in question. Prospective randomized controlled trials are currently underway in humans to help clarify the situation further and there results are awaited with anticipation. The negative impact of pain on the immune system is well documented and it appears that appropriate analgesia is paramount in minimizing this. Opioids still constitute a central role in the management of moderate-to-severe cancer pain.
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Curr Opin Support Palliat Care · Mar 2014
ReviewThe provision of home-based palliative care for those with advanced heart failure.
Although widely recognized as best practice for advanced heart failure patients, palliative care is underused by this population. The purpose of this brief review is to highlight recent findings related to home-based palliative care among patients with advanced heart failure. ⋯ New models integrating home-based palliative care and standard heart failure care have shown to be effective in reducing both physical and psychological symptoms in patients. Recent evidence suggests that home-based palliative care reduces hospitalizations and decrease the probability of 30-day re-admissions in patients with advanced heart failure; thus, potentially reducing costs of care and increasing likelihood of dying at home. However, caregiver burden for families of those with heart failure remains an issue. Research that addresses caregiver burden and the challenges of providing palliative care to patients with the uncertain disease trajectory seen in advanced heart failure require further research.
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Curr Opin Support Palliat Care · Dec 2013
ReviewNutritional counseling and nutritional supplements: a cornerstone of multidisciplinary cancer care for cachectic patients.
The challenge with cancer cachexia is that it is not fully reversed by nutrition support. The purpose of this review is to provide an opinion on the nutritional management of cancer cachexia based on the most recent available evidence. ⋯ Further research into the most appropriate methods for identifying and treating cancer cachexia is required. Regardless of whether patients are experiencing reduced dietary intake resulting in malnutrition or due to cachexia, nutrition remains a cornerstone of multimodal treatment.