One hundred eleven patients with advanced cancer and pain newly referred to a palliative care center completed the Brief Pain Inventory (BPI) weekly for up to 4 weeks. The aims were (a) to review the numbers and causes of pain, (b) to consider the usefulness of the BPI in the evaluation of pain in cancer patients, and (c) to determine the impact of treatment. A total of 370 pains were recorded initially, a median of 3 per patient; 85% had more than 1 pain and more than 40% had 4 or more pains. Causes of pain were cancer (46%), debility (29%), treatment (5%), concurrent disorder (8%), and no stated cause (12%). The top 10 individual causes accounted for 73% of the pains. Seventy-six (68%) of the patients completed two BRIs, but only 46 (41%) completed 5. After 4 weeks, the median number of pains had fallen to 1.5; 78% still had more than 1 pain, but only 20% had 4 or more pains. Intensity of pain also declined, particularly in the first 2 weeks. With their last BPI, 23% had become completely pain free and a further 27% achieved acceptable relief (worst pain scores 1-4), compared with none and 24% initially. Of those who completed all five BPIs, the final respective figures were 22% and 29%. In contrast, 23% of patients still had unacceptable severe pain noted on their last BPI (worst pain scores 8-10), compared with 36% initially. Of those who completed five BPIs, the final figure was 20%. Highly significant correlations were observed between all seven interference factors and present, worst, and average pain intensities. After 4 weeks, the pattern was more variable, particularly in relation to present pain, suggesting that interference factors may have a limited utility as a measure of satisfactory pain management. Many patients did not answer all the questions in the BPI. It was concluded that the BPI is not brief enough for routine clinical use, and that the short form of the BPI (BPI-SF) is too short. A pain diary card will be developed comprising mainly pain scores, a pain relief score and a satisfaction with pain management score.
A computerized system for monitoring drug use which makes use of the British National Formulary (BNF) drug categories and a departmental formulary (DF) has been developed. Data entry takes less than one week of secretarial time per annum. Details of drug use in 385 patients three weeks after referral to a National Health Service palliative care unit over five years form the basis of this report. The median number of drugs per patient was five, with a maximum of 11; 97% of the drugs were from the DF. Analgesics were the commonest category of drugs used. The 10 most commonly used drugs included three analgesics (morphine, co-proxamol, flurbiprofen), two laxatives (co-danthrusate, lactulose), dexamethasone, metoclopramide, ranitidine, temazepam and amitriptyline/dothiepin. Seventeen per cent of patients received two preparations from the same second level BNF category (analgesics excluded). The concurrence was questionable in about half of these, and mostly related to the use of laxatives or to hypnotics and anxiolytics. Several unexpected inclusions in the top 10 drugs illustrate the need for quantification rather than pontification about drug use in palliative care. Examination of duplicate prescribing provides a forum for examining ways of simplifying drug regimens.
Data for 714 patients referred during a 5-year period to a specialist lymphoedema service in Oxford, UK, have been recorded on a database. The annual number of new patients almost doubled from 103 to 195. In addition to initial assessments, there were over 1000 follow-up appointments per year. Most patients were seen as out-patients. Fifty-six per cent of the referrals were from Oxfordshire and the rest from further afield. The two largest groups referring patients to the service were general practitioners (43%) and the radiotherapy department (26%). Most referrals were female (84%), and the main cause of lymphoedema was cancer and cancer treatments (68%). After 2 years, only 15% of patients were still attending the clinic regularly. The number of patients receiving intensive treatment increased by almost 40%. These findings emphasize the need to target resources and expertise selectively in order to provide an optimal service to patients needing specialist help.
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