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Endoscopic Palliation for Pancreatic Cancer  [PDF]
Mihir Bakhru,Bezawit Tekola,Michel Kahaleh
Cancers , 2011, DOI: 10.3390/cancers3021947
Abstract: Pancreatic cancer is devastating due to its poor prognosis. Patients require a multidisciplinary approach to guide available options, mostly palliative because of advanced disease at presentation. Palliation including relief of biliary obstruction, gastric outlet obstruction, and cancer-related pain has become the focus in patients whose cancer is determined to be unresectable. Endoscopic stenting for biliary obstruction is an option for drainage to avoid the complications including jaundice, pruritus, infection, liver dysfunction and eventually failure. Enteral stents can relieve gastric obstruction and allow patients to resume oral intake. Pain is difficult to treat in cancer patients and endoscopic procedures such as pancreatic stenting and celiac plexus neurolysis can provide relief. The objective of endoscopic palliation is to primarily address symptoms as well improve quality of life.
Evaluation of a combination of low-dose ketamine and low-dose midazolam in terminal dyspnea-attenuation of "double-effect"  [cached]
Dam Abhijit
Indian Journal of Palliative Care , 2008,
Abstract: Aim: Of all symptoms in palliative medicine those concerning respiration are most excruciating and difficult to treat. Reticence about the use of morphine for palliation of dyspnea is common, especially in nonmalignant diseases, as there is a fear of causing respiratory depression, particularly where Chronic Obstructive Pulmonary Disease (COPD) exists. This factor is also compounded by the lack of availability of morphine in parts of developing countries. Ketamine has excellent anesthetic and analgesic effects in addition to being easily available. It produces bronchodilatation and does not produce respiratory or cardiovascular depression. The author seeks to evaluate the role of low-dose (0.2 mg/kg) ketamine and midazolam (0.02 mg/kg) in the attenuation of terminal dyspnea. Methods: Sixteen patients with terminal dyspnea, admitted to the Critical Care Unit (CCU) with cancer and other noncancer diagnoses were recruited. The subjective component of dyspnea was assessed using the Graphic Rating Scale (GRS), which has values from 0 - 10, 10 being maximum dyspnea. Each patient received a low-dose of ketamine and midazolam for relief of dyspnea. All the patients received low-flow (2 L/min.) oxygen therapy via nasal cannula. Immediately after admission, all the patients were reassured and nursed in a decubitus position of their choice. The GRS was recorded at the point of admission, 10 minutes after starting oxygen therapy, and ten minutes after administration of low-dose ketamine and midazolam. Hemodynamic parameters were also recorded at these three points. Result: All the patients who enrolled in our study had significant dyspnea at admission, as was evident from the GRS scores of 8.250 (SD 0.91), respiratory rate of 28.56 (SD 5.0), mean arterial blood pressure (MABP) of 102.7 (SD 14.63), pulse rate of 115.62 (SD 23.3), and SpO2 of 92.43 (SD 2.38). All the patients benefited from the combination of ketamine and midazolam, as evidenced by the statistically significant ( P < 0.01) improvement in all monitored parameters. Conclusion: The author concludes that a combination of low-dose ketamine and midazolam can be safely used in the palliation of terminal dyspnea, with excellent results. The duration of action of this combination in providing symptomatic relief is however short-lived, being 36.7 minutes on an average (SD 5.23), thus necessitating intermittent IV top-ups. No adverse reports were obtained in the study.
To use or not to use: an update on licit and illicit ketamine use
Jih-Heng Li,Balasingam Vicknasingam,Yuet-wah Cheung,et al
Substance Abuse and Rehabilitation , 2011,
Abstract: Jih-Heng Li1, Balasingam Vicknasingam2, Yuet-wah Cheung3, Wang Zhou4, Adhi Wibowo Nurhidayat5, Don C Des Jarlais6, Richard Schottenfeld71College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; 2National Centre for Drug Research, Universiti Sains Malaysia, Malaysia; 3Department of Sociology, The Chinese University of Hong Kong, Hong Kong, China; 4Wuhan Center for Disease Control and Prevention, Wuhan, China; 5Drug Dependence Hospital RSKO, Jakarta, Indonesia; 6Beth Israel Medical Center, New York, NY; 7School of Psychiatry, Yale University, CT, USAAbstract: Ketamine, a derivative of phencyclidine that was developed in the 1960s, is an anesthetic and analgesic with hallucinogenic effects. In this paper, the pharmacological and toxicological effects of ketamine are briefly reviewed. Ketamine possesses a wide safety margin but such a therapeutic benefit is somewhat offset by its emergence phenomenon (mind-body dissociation and delirium) and hallucinogenic effects. The increasing abuse of ketamine, initially predominantly in recreational scenes to experience a “k-hole” and other hallucinatory effects but more recently also as a drug abused during the workday or at home, has further pushed governments to confine its usage in many countries. Recently, urinary tract dysfunction has been associated with long-term ketamine use. In some long-term ketamine users, such damage can be irreversible and could result in renal failure and dialysis. Although ketamine has not yet been scheduled in the United Nations Conventions, previous studies using different assessment parameters to score the overall harms of drugs indicated that ketamine may cause more harm than some of the United Nations scheduled drugs. Some countries in Southeast and East Asia have reported an escalating situation of ketamine abuse. Dependence, lower urinary tract dysfunction, and sexual impulse or violence were the most notable among the ketamine-associated symptoms in these countries. These results implied that the danger of ketamine may have been underestimated previously. Therefore, the severity levels of the ketamine-associated problems should be scrutinized more carefully and objectively. To prevent ketamine from being improperly used and evolving into an epidemic, a thorough survey on the prevalence and characteristics of illicit ketamine use is imperative so that suitable policy and measures can be taken. On the other hand, recent findings that ketamine could be useful for treating major depressive disorder has given this old drug a new impetus. If ketamine is indeed a remedy fo
Prótesis Choostent como método de paliación de la disfagia secundaria a patología maligna Use of Choostent prosthetic device for palliation of dysphagia secondary to esophageal cancer  [cached]
Mario Anselmi M,Ana María Gemmato P,Antonio Rodríguez D
Revista Chilena de Cirugía , 2012,
Abstract: Objetivo: Analizar en forma prospectiva los resultados de la inserción de una prótesis metálica autoex-pandible cubierta tipo Choostent como método de paliación de la disfagia, fístulas o fugas esofágicas secundarias a patología maligna del esófago o cardias. Material y Método: Se estudiaron un total de 30 pacientes consecutivos portadores de patología maligna del esófago o de cardias. La edad promedio fue de 75 ± 8,8 a os. 19 (63,3%) eran del género masculino. En 27 pacientes (90%) la estenosis comprometía el esófago, en 2 (6,7%) la unión gastroesofágica y en 1 (3,3%) la anastomosis esófago yeyunal por recidiva tumoral. En 24/30 casos (80%), la indicación de la prótesis fue la disfagia, en 3 (10%) la presencia de fístula esófago-traqueal y en los 3 restantes (10%), la sospecha de perforación. Los pacientes fueron controlados hasta su fallecimiento. Resultados: La prótesis se insertó sin incidentes en 29/30 pacientes (96,7%). Un caso (3%) presentó neumo-mediastino, que evolucionó favorablemente. La disfagia cedió en la totalidad de los enfermos. La evolución precoz fue satisfactoria en 12/30 pacientes (40%), siendo la complicación precoz más frecuente el dolor torácico transitorio en 3 casos (10%). Fallecieron precozmente 4 enfermos (13,3%). De los 26 restantes, en 14 (53,8%) se presentaron complicaciones tardías, siendo las más frecuentes la recidiva de la disfagia (42,3%) y la hemorragia (11,5%). Conclusión: Las prótesis Choostent mejoran la disfagia en forma inmediata y segura. Son efectivas en el manejo de las fístulas traqueo-esofágicas y perforaciones. Sin embargo, su uso se asocia a una alta tasa de morbilidad tardía directamente relacionada a la disfunción protésica. Background: Esophageal cancer causes disabling dysphagia and swallowing problems. Aim: To prospectively analyze the outcome of the insertion of a covered self-expanding metallic Choostent type prosthesis as a method of palliation of dysphagia, esophageal fistula or leak secondary to malignant disease of the esophagus or cardia. Material and Methods: A total of 30 consecutive patients aged 75 ± 8.8 years (63% males) with malignant disease of the esophagus or cardia were studied. Results: In 27 patients (90%) the stenosis was located in the esophagus, in two (6.7%) at the gastroesophageal junction and in one (3.3%) at the esophago - jejunal anastomosis due to tumor recurrence. In 24 cases (80%), the indication of the prosthesis was dysphagia, in three (10%) the presence of a tracheo-esophageal fistula and in the remaining three (10%), the suspicion of a perforation. Patients were foll
Cystitis due to the use of ketamine as a recreational drug: a case report
Britt Colebunders, Peter Van Erps
Journal of Medical Case Reports , 2008, DOI: 10.1186/1752-1947-2-219
Abstract: We describe the case of a 20-year-old man who presented with a 7-month history of urinary frequency, nocturia, urgency, suprapubic discomfort during micturition and episodes of severe haematuria shortly after commencing weekly recreational ketamine use. Complementary examinations were negative except for a thickened bladder wall on ultrasound examination and mild inflammatory changes on cystoscopy. So far only nine cases of ketamine-associated ulcerative cystitis have been described.We expect that in the future an increasing number of cases of cystitis caused by ketamine use will be seen in young adults.Ketamine is a derivative of phencyclidine, a popular street drug which is known as 'PCP' or 'angel dust'. Ketamine is less potent and shorter acting compared with phencyclidine and is used as a dissociative anaesthetic in humans [1]. Ketamine, known as 'Special K', is becoming more widely used among young adults attending clubs and parties, including raves [2]. It is labelled a 'club drug' by the National Institute on Drug Abuse (NIDA) of the United States. The effects of ketamine include profound changes in consciousness and psychotomimetic symptoms, such as out-of-body experiences [3]. It can also induce a state of virtual helplessness and a pronounced lack of coordination [4]. Negative effects include increased heart and respiratory rates, nausea and vomiting, convulsions, temporary paralysis and hallucinations [2]. So far only one report has described the effect of ketamine on the urinary system: nine patients were found to have developed a ketamine-associated ulcerative cystitis [5]. We report an additional case.We describe the case of a 20-year-old man who presented with a 7-month history of urinary frequency, nocturia, urgency, suprapubic discomfort during micturition and episodes of severe haematuria shortly after commencing weekly recreational ketamine use. The patient occasionally works as a disk jockey at 'hardstyle' and 'jump' parties. His past medical hi
The Use of Intravenous Neostigmine in Palliation of Severe Ileus  [PDF]
Pashtoon Murtaza Kasi
Case Reports in Gastrointestinal Medicine , 2013, DOI: 10.1155/2013/796739
Abstract: Neostigmine is a parasympathomimetic drug that acts as a reversible acetylcholinesterase inhibitor. Clinically it is used in patients with acute colonic pseudo-obstruction (ACPO or Ogilvie’s syndrome, which is a gastrointestinal motility disorder characterized by marked dilatation of the colon in the absence of mechanical obstruction), postoperative ileus, urinary retention, myasthenia gravis, and in anesthesia to reverse the effects of nondepolarizing muscle relaxants. Both bolus and infusion are noted to be effective and lead to prompt evacuation of flatus or stool with a reduction in abdominal distention on physical examination. Median duration is noted to be 4–30 minutes in some trials. Here we present our experience of using 2?mg of intravenous neostigmine to help relieve the severe abdominal distention and ileus in a patient with severe fecal impaction when all conservative measures had been futile. The most frequent side effect of the drug is abdominal pain/cramping, which was noted in our patient as well. Other complications include bradycardia which is very infrequently symptomatic to require atropine. Overall, the drug is a simple, safe, and effective strategy; and as pointed out in the previous studies, the drug appears to be underused in patients who do not have a true contraindication to its use. 1. Case Presentation A 76-year-old man with a past medical history significant for cerebrovascular accident (CVA) with severe residual right-sided hemiplegia/aphasia (bedbound), vascular dementia, HTN, and depression was admitted to our service from a nursing home because of worsening abdominal distention and pain from severe constipation since several weeks apparently. Per nursing home records, patient had been having problems with constipation for the last 2-3 weeks. At the nursing facility, they had tried all kinds of oral stool softeners/laxatives including magnesium citrate, docusate, senna, polyethylene glycol, and prune juices followed by enemas (soap suds enemas and fleet enemas) with no results. Prokinetic drugs (including erythromycin and metoclopramide) were also tried. Methylnaltrexone (Relistor) injections were also administered at the facility as well with no outcome. Given progressive worsening in his abdominal distention/pain, along with ongoing constipation, patient was brought to our tertiary care facility for further care and management. At the time of admission, a computerized tomography (CT) scan of his abdomen was done which unfortunately revealed very severe fecal impaction (Figure 1). According to radiology, significant
Endoscopic palliation of malignant dysphagia: a challenging task in inoperable oesophageal cancer
IE Katsoulis, A Karoon, S Mylvaganam, JI Livingstone
World Journal of Surgical Oncology , 2006, DOI: 10.1186/1477-7819-4-38
Abstract: All the endoscopic palliative procedures performed over a 5-year period in our unit were retrospectively reviewed. Dilatation and insertion of self-expandable metal stents (SEMS) were mainly used for tight circumferential strictures whilst ablation with Nd-YAG laser was used for exophytic lesions. All procedures were performed under sedation.Overall 249 palliative procedures were performed in 59 men and 40 women, with a median age of 73 years (range 35 – 93). The median number of sessions per patient was 2 (range 1 – 13 sessions). Palliation involved laser ablation alone in 24%, stent insertion alone in 22% and dilatation alone in 13% of the patients. In 41% of the patients, a combination of the above palliative techniques was applied. A total of 45 SEMS were inserted. One third of the patients did not receive any other palliative treatment, whilst the rest received chemotherapy, radiotherapy or chemoradiotherapy. Swallowing was maintained in all patients up to death. Four oesophageal perforations were encountered; two were fatal whilst the other two were successfully treated with covered stent insertion and conservative treatment. The median survival from diagnosis was 10.5 months (range 0.5–83 months) and the median survival from 1st palliation was 5 months (range 0.5–68.5 months).Endoscopic interventions are effective and relatively safe palliative modalities for patients with oesophageal cancer. It is possible to adequately palliate almost all cases of malignant dysphagia. This is achieved by expertise in combination treatment.Oesophageal cancer is a relatively rare disease. The average age standardised incidence rate in the EU for the year 2004, was 9.5 per 100,000 of male population and 8.7 per 100,000 of female population [1]. Patients with oesophageal cancer and cancer of the gastro-oesophageal junction (GOJ) commonly present with advanced disease mainly because the oesophagus is quite distentable and patients may not experience dysphagia until almost half o
The epidemiology and patterns of acute and chronic toxicity associated with recreational ketamine use  [cached]
Sarbjeet S. Kalsi,David M. Wood,Paul I. Dargan
Emerging Health Threats Journal , 2011, DOI: 10.3402/ehtj.v4i0.7107
Abstract: Ketamine was originally synthesised for use as a dissociative anaesthetic, and it remains widely used legitimately for this indication. However, there is increasing evidence of non-medical recreational use of ketamine, particularly in individuals who frequent the night-time economy. The population-level and sub-population (clubbers) prevalence of recreational use of ketamine is not known but is likely to be similar, or slightly lower than, that of other recreational drugs such as cocaine, MDMA, and amphetamine.The predominant features of acute toxicity associated with the recreational use of ketamine are neuro-behavioural abnormalities such as agitation, hallucinations, anxiety, and psychosis. Secondary to these, individuals put themselves at greater risk of physical harm/trauma. Cardiovascular features (hypertension and tachycardia) occur less frequently and the risk of death from recreational use is low and is predominately due to the physical harm/trauma.Long-term recreational use of ketamine can be associated with the development of psychological dependence and tolerance. There are reports of gastro-intestinal toxicity, particularly abdominal pain and abnormal liver function tests, and of neuropsychiatric disorders, typically a schizophrenia-like syndrome, in long-term users. Finally, there are increasing reports of urological disorders, particularly haemorrhagic cystitis, associated with long-term use. The management of these problems associated with the long-term use of ketamine is largely supportive and abstinence from ongoing exposure to ketamine.In this review we will collate the available information on the epidemiology of recreational use of ketamine and describe the patterns of acute and chronic toxicity associated with its recreational use and the management of this toxicity.
Use of Ketamine in Severe Status Asthmaticus in Intensive Care Unit
Farhad Heshmati,Mohamad B. Zeinali,Heydar Noroozinia,Rahman Abbacivash
Iranian Journal Of Allergy, Asthma and Immunology , 2003,
Abstract: Bronchial asthma represents an increased airways responsiveness to vari ous stimulants, leading to reversible obstruction of expiratory flow and chronic inflammatory changes in airways wall. Ketamine has been demonstrated to lower airway resistance and to increase lung compliance in the asthmatic patients. In several studies and case reports it has been used successfully in the management of status asthmaticus, resistant to conventional therapy, but so far no clinical trial has been carried out to support this empirical use of ketamine. For this reason, we designed a prospective observational study.Eleven, 15-40 years old patients, with status asthmaticus whose respiratory failure did not respond to conventional therapy and mechanical ventilation (after 24h), were entered in this study (provided that there were not any contraindications to ketamine use). These patients received ketamine at a load ing dose of 1 mg/kg (IV), followed by a continuous infusion of 1 mg/kg/hr for 2h. Peak airway pressure, PaC02 and Pa02 were measured prior to ketamine ad ministration, 15min after administration and 2h after infusion of ketamine. Mean peak airway pressure and PaC02 significantly decreased 15min and 2h after administration and infusion of ketamine (p<0.005) and Pa02 significantly in creased in these time intervals (p<0.005).Ketamine is a useful and safe drug in the intensive treatment of status asthmaticus. However, ketamine should only be used for asthmatics whose res piratory failure does not respond to standard therapy.
Surgical palliation of unresectable pancreatic head cancer in elderly patients  [cached]
Sang Il Hwang, Hyung Ook Kim, Byung Ho Son, Chang Hak Yoo, Hungdai Kim, Jun Ho Shin
World Journal of Gastroenterology , 2009,
Abstract: AIM: To determine if surgical biliary bypass would provide improved quality of residual life and safe palliation in elderly patients with unresectable pancreatic head cancer.METHODS: Nineteen patients, 65 years of age or older, were managed with surgical biliary bypass (Group A). These patients were compared with 19 patients under 65 years of age who were managed with surgical biliary bypass (Group B). In addition, the results for group A were compared with those obtained from 17 patients, 65 years of age or older (Group C), who received percutaneous transhepatic biliary drainage to evaluate the quality of residual life.RESULTS: Five patients (26.0%) in Group A had complications, including one intraabdominal abscess, one pulmonary atelectasis, and three wound infections. One death (5.3%) occurred on postoperative day 3. With respect to morbidity, mortality, and postoperative hospitalization, no statistically significant difference was noted between Groups A and B. The number of readmissions and the rate of recurrent jaundice were lower in Group A than in Group C, to a statistically significant degree (P = 0.019, P = 0.029, respectively). The median hospital-free survival period and the median overall survival were also significantly longer in Group A (P = 0.001 and P < 0.001, respectively).CONCLUSION: Surgical palliation does not increase the morbidity or mortality rates, but it does increase the survival rate and improve the quality of life in elderly patients with unresectable pancreatic head cancer.
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