Journal of palliative medicine
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Levorphanol has been reported to provide analgesia at doses that suggest it does not act like other pure agonist opioids. A dual effect of action on both opioid receptors and n-methyl, d-aspartate (NMDA) receptors has been proposed to be responsible for this effect. ⋯ These results suggest that levorphanol has a role in the treatment of pain syndromes that are refractory to other opioids. The pattern of relief seen in this case series is similar to that reported for methadone. Could it be that levorphanol may have a role like methadone for pain that is poorly controlled with other pure agonist opioids? We summarize what is known about levorphanol and provide a table for converting other opioids to levorphanol that was used for this case series.
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Comparative Study
Influence of patient and physician characteristics on percutaneous endoscopic gastrostomy tube decision-making.
Data are lacking to support percutaneous endoscopic gastrostomy (PEG) tube placement in advanced dementia, yet it is common, especially in the southeast United States and in African Americans. In a cross-sectional survey, we examine whether physicians recommend PEG placement more for African American than Caucasian patients and identify physician characteristics related to recommendation for PEG. ⋯ In this survey, recommendation for PEG tube feeding differed significantly by physician race and specialty, and not by race of the case patient. Additional research is needed to measure whether real-life treatment recommendations vary by physician race, physician-patient race concordance and physician specialty.
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Opioid switching is often used to improve the opioid response in patients with cancer experiencing poor analgesia or adverse effects. When switching between drugs with delayed effect because of pharmacokinetics or type of delivery, concerns exist about the correct timing of introducing the second drug after stopping the previous one. The aim of this study was to assess plasmatic changes of fentanyl and methadone underlying the clinical events occurring during opioid switching. ⋯ Conversion ratios between opioids at time of stabilization did not significantly change in comparison with the initial conversion ratio chosen. Starting methadone soon after removing fentanyl patches results in a rapid increase of methadone concentration, while the half-life of transdermal fentanyl is reached after 25 hours. As a result, the rapid achievement of a clinical effect is obtained avoiding distressing therapeutic holes in patients with a clinical condition, mainly characterized by poor pain control and severe adverse effects, requiring an immediate intervention.
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To determine how palliative and end-of-life care can best be incorporated into the training of pediatric residents. ⋯ For palliative care principles to be better incorporated into pediatric practice, they must be incorporated into residency education, optimally through informal teaching and during rounds. Finding ways to teach residents palliative medicine during clinical "teachable moments" and standardizing didactic curricula should become a priority in palliative and end-of-life care education.
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Editorial Comment
Is length of stay on hospice a critical quality of care indicator?