[Pain relief in metastatic bone disease]

BOÉR Katalin

OCTOBER 20, 2011

LAM KID - 2011;1(02)

[Metastatic bone disease is a hallmark of distant relapse of a number of solid tumours. The treatment of bone metastases is palliative, the main goal is to relieve pain, whereas it’s also important to reduce the risk of bone fractures, prolong survival and maintain the physical activity of patients. Pain is one of the most common symptoms of bone metastases, and state-of-the-art pain relief has an important role in maintaining the patients’ quality of life. Therapies to control pain include drug therapy, radiotherapy, surgery, systemic oncotherapy, such as chemotherapy and/or hormone therapy, multibone radioisotope therapy and administration of bisphosphonates. Regarding the relief of pain caused by malignant tumours, the guidelines developed by the World Health Organization should be followed. The algorithm of pain relief starts with assessment of the pain’s intensity and includes both pharmacological and nonpharmacological interventions. Analgesics used for pain relief include nonopioids, opioids and adjuvant agents. The pain can be efficiently relieved with the combined use of modern analgesics in the great majority of patients.]



Further articles in this publication


[Inhibition of receptor activator of nuclear kappa-B ligand: pathophysiology and preclinical data]


[Bone remodeling is a lifelong process, in which the balanced functions of osteoclasts and osteoblasts have a key role. In certain conditions, for example during the dramatical hormonal changes in the postmenopausal period, the upset of this balance leads to a pathologically increased bone loss. Such conditions lead to an increased bone loss, which results in an increased risk of fractures. Bone resorption is primarily regulated by a member of the tumor necrosis factor family, receptor activator of nuclear factor κB ligand, which plays a central role in the development, function and survival of osteoclasts. Catabolic effects of this ligand is inhibited by another member of the tumor necrosis factor family, osteoprotegerin, which binds to the ligand and prevents its interaction with its receptor, the receptor activator of nuclear factor κB. Osteoclast activity is at least partly dependent on the relative balance of the ligand and osteoprotegerin. It has been shown in a number of animal models that inhibition of the ligand markedly decreases bone resorption and increases cortical and cancellous bone volume, density and strength, without having any significant effect on other organs. On the basis of these findings, inhibition of receptor activator of nuclear κB ligand is a promising therapy of conditions characterised by increased bone loss. In phase 3 clinical trials, denosumab therapy significantly increased bone mineral density at various regions of the skeleton and significantly decreased the levels of bone turnover markers compared with placebo and alendronate therapy, and significantly decreased the incidence of new vertebral, total hip and nonvertebral fractures compared with placebo. On the basis of these findings, denosumab therapy offers a novel, revolutionary solution for the treatment of postmenopausal osteoporosis.]


[Pain relief in the neurologist’s view]


[Pain, on the basis of its anatomical origin, can be nociceptive (somatic, visceral) or neuropathic, that is, occuring as a direct consequence of a lesion or disease affecting the somatosensory system. The past few years’ epidemiological studies showed that chronic neuropathic pain affects 7-8% of the general population. Diagnosis of neuropathic pain can be established without instrumental examinations, with the help of validated tests that can be used by any physician. Neuropathic pain greatly deteriorates the patients’ quality of life, and the effect of traditional analgesics is insufficient for its treatment. Thus, it is important to know those treatment procedures and drugs that have been proved to be efficient for relieving neuropathic pain.]


[Pain management in rheumatology]

NAGY Katalin

[Pain is the most common symptom in rheumatology, which can be of mechanical or inflammatory origin, acute and chronic, nociceptive, neuropathic and psychogenic. Pain can be relieved by analgesics, nonsteroidal anti-inflammatory drugs, opioids, adjuvants and special drugs depending on the etiology, for example a gout attack can be stopped by colchicine. For pain relief, we use therapeutic guidelines of the World Health Organization (WHO), which recommends the use of analgesics, NSAIDs and adjuvants as the first step, weaker opioids as the second, and strong opioids as the third step. In rheumatology, the first step's drugs are generally used. If possible, NSAIDs should be administered briefly, potentially combined with analgesics and muscle relaxants. If pain management is insufficient, tramadol should be given. Pain relief in rheumatology also include the use of local and intraarticular injections, physiotherapy, TENS and balneotherapy. Complex therapies that combine the above mentioned methods is often more effective than the use of medications only.]


[Osteoid osteoma]



[Connections of bone turnover and energy homeostasis in women]


[BACKGROUND - A new discovery of the past decade has been the previously unknown relationship between the bone metabolic unit and energy homeostasis. On the basis of data from previous animal and clinical studies, osteocalcin has been considered the major mediator of this relationship. Cathepsin K is a cysteine protease type osteolytic enzyme, which has a role in bone resorption, and which is a pharmaceutical target in the treatment of osteoporosis and bone metastasis. According to data from animal studies, its deficiency or selective inhibition decreases the differentiation of preadipocytes, body weight and serum levels of insulin and glucose in obese mice. The aim of our study was to elucidate the role of cathepsin K in the human bone - metabolic axis in women (n=66). PATIENTS AND METHODS - 21 healthy and 45 glucose intolerant women were examined. OGTT, IVGTT and hyperinsulinaemic euglycaemic clamp were performed to assess carbohydrate homeostasis, insulin secretion, whole-body and muscle glucose utilization (M-1 and M-3). Circulating levels of bone markers and adipokines were measured, and DEXA was used to measure BMD, fat and muscle mass. RESULTS - Cathepsin K levels showed a significant (p<0.05), negative correlation with BMI, body fat percent and OGTT glucose and insulin area under the curve (AUC), and a positive correlation with M values. No correlation was found between cathepsin K levels and IVGTT measurements. CONCLUSION - Cathepsin K - in women - is not only a participant of the bone metabolism - energy homeostasis axis. Its role in human glucose homeostasis differs from what could be expected on the basis of animal experiments, because increasing cathepsin K levels indicate, paradoxically, improving metabolic state in women. Our data suggest that insulin regulation of cathepsin K is mediated by the incretin system.]

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Clinical Neuroscience

[Disease burden of Duchenne muscular dystrophy patients and their caregivers]


[Background and purpose - Data on the disease burden of Duchenne Muscular Dystrophy are scarce in Hungary. The aim of this study was to assess patients’ and their caregivers’ health related quality of life and healthcare utilisations. Methods - A cross sectional survey was performed as part of the European BURQOL-RD project. The EQ-5D-5L and Barthel Index questionnaires were applied, health care utilisations and patients’ informal carers were surveyed. Results - One symptomatic female carer, 50 children (boys 94%) and six adult patients (five males) participated in the study, the latter two subgroups were included in the analysis. The average age was 9.7 (SD=4.6) and 24.3 (SD=9.8) years, respectively. Median age at time of diagnosis was three years. The average EQ-5D score among children and adults was 0.198 (SD=0.417) and 0.244 (SD=0.322), respectively, the Barthel Index was 57.6 (SD=29.9) and 53.0 (SD=36.5). Score of satisfaction with healthcare (10-point Likert-scale) was mean 5.3 (SD=2.1) and 5.3 (SD=2.9). 15 children were hospitalised in the past 12 months for mean 12.9 (SD=24.5) days. Two patients received help from professional carer. 25 children (mean age 11.1, SD=4.4 years) were helped/supervisied by principal informal carer (parent) for mean 90.1 (SD=44.4) hours/week and further family members helped in 21 cases. Correlation between EQ-5D and Barthel Index was strong and significant (0.731; p<0.01) as well as with informal care time (-0.770; p<0.01), but correlation with satisfaction with health care was not significant (EQ-5D: 0.241; Barthel Index: 0.219; informal care: -0.142). Conclusion - Duchenne muscular dystrophy leads to a significant deterioration in the quality of life of patients. Parents play outstanding role in the care of affected children. This study is the first in the Central and Eastern European region that provides quality of life data in this rare disease for further health economic studies.]

Clinical Neuroscience

[The quality of life of the cluster headache patients during the active phase of the headache]


[Introduction - Cluster headache (CH), which affects 0.1% of the population, is one of the most painful human conditions: despite adequate treatment, the frequent and severe headaches cause a significant burden to the patients. According to a small number of previous studies, CH has a serious negative effect on the sufferers’ quality of life (QOL). In the current study, we set out to examine the quality of life of the CH patients attending our outpatient service between 2013 and 2016, using generic and headache-specific QOL instruments. Methods - A total of 42 CH patients (16 females and 26 males; mean age: 39.1±13.5 years) completed the SF-36 generic QOL questionnaire and the headache- specific CHQQ questionnaire (Comprehensive Headache- related Quality of life Questionnaire), during the active phase of their headache. Their data were compared to those of patients suffering from chronic tension type headache (CTH) and to data obtained from controls not suffering from significant forms of headache, using Kruskal-Wallis tests. Results - During the active phase of the CH, the patients’ generic QOL was significantly worse than that of normal controls in four of the 8 domains of the SF-36 instrument. Apart from a significantly worse result in the ‘Bodily pain’ SF-36 domain, there were no significant differences between the CH patients’ and the CTH patients’ results. All the dimensions and the total score of the headache-specific CHQQ instrument showed significantly worse QOL in the CH group than in the CTH group or in the control group. Conclusion - Cluster headache has a significant negative effect on the quality of life. The decrease of QOL experienced by the patients was better reflected by the headache-specific CHQQ instrument than by the generic SF-36 instrument. ]

Journal of Nursing Theory and Practice

Use of Imogene King’s Nursing Model in the Care for a Patient with Heart Arrhythmias


Objectives: To discover the benefits of implementation of Imogene King’s nursing model into nursing care in a patient with arrhythmias. To find out how these patients are limited in saturation of their own needs and what are the most severe limitations for patients with arrhythmias. Material and methods: Qualitative research using semi-structured interviews. The interview with patients with arrhythmia was conducted in accordance with the structure of King’s nursing model. Results: The research group consisted of 20 respondents; 13 men and seven women. All respondents expressed satisfaction with their cooperation with staff. The respondents described a change in the subjectively perceived state, the psychic state, and emotions. Conclusions: Assessment of the subjectively perceived quality of life of patients with arrhythmias using the King’s interaction model allows nurses to see the patient from the holistic point of view and plan and provide individualized care.


[Quality of life of patients with osteoporosis in Hungary]

VOKÓ Zoltán, INOTAI András, HORVÁTH CSABA, BORS Katalin, SPEER Gábor, KALÓ Zoltán

[AIM - The aim of our study was to estimate the loss of quality of life due to osteoporotic fractures. We performed a cross-sectional study including 840 patients in 21 centers that specialise in the care of patients with osteoporosis and in acute care of fractures. METHODS - Patients were selected randomly and stratified for the location of and time elapsed since the fracture. Quality of life (QoL) was assessed by the Qualeffo-41 and the EuroQol-5D questionnaires. RESULTS - Patients with morphometric fractures of more than one vertebra had the lowest median EQ-5D index value (0.59). Symptomatic vertebral, hip and arm fractures also considerably decreased QoL. Patients with morphometric fractures of more than one vertebra had the lowest total Qualeffo-41 score. When controlled for age and gender, patients with hip fracture or morphometric vertebral fracture had at least 0.2 less mean utility values than had osteoporotic patients without history of fracture. Patients with more than a oneyear history of hip fracture had QoL scores as low as had patients with an acute fracture. In case of wrist and arm fractures, the acute loss of QoL somewhat decreased with time. CONCLUSION - In conclusion, osteoporotic fractures, especially hip and vertebral fractures result in a significant loss of patients’ quality of life. Our results show that physicians need to pay a close attention to morphometric vertebral fractures, which contribute to a great loss of human capital.]

Clinical Neuroscience

[Effects of neural therapy on quality of live in patients with inoperable lower extremity artery disease ]

MOLNÁR István, DEÁK Botond Zsolt, HEGYI Gabriella, KOVÁCS Zoltán, KAPÓCS Gábor, SZŐKE Henrik

[Objectives - Our aim was to evaluate the effects of percutaneous neurolysis of lumbal sympathetic ganglions on pain and the resulting changes in quality of life with validated objective and subjective methods. To follow the adverse effects and complications of the procedure. Materials and methods - A prospective, non-randomized, interventional, clinical cohort study under real life conditons was conducted. The time of the observation was 6 months. Palliative neural therapy was performed to reduce the ischemic pain of the affected leg of the patients involved in the study. Prior to treatment and after 35 days, Visual Analogue Scale (VAS) was used to measure the intensity of lower limb pain. The related changes in the quality of life were followed by a general 36-Item Short-Form Health Survey (SF-36) questionnaire. We measured the changes of the patients’ skin temperature and ankle/arm index. The post-treatment results were compared to the pre-treatment results. We compared the results of objective and subjective measures. We followed the side effects and complications of the pain therapy. Each of the examined subjects had obliterative (Fontaine II/b stage) arterial disease of the lower limbs, in which no revascularization intervention was feasible and their ischemic pain was of VAS≥7. Results - Data of 124 patients (69 male, 55 female) could be evaluated. The decrease in intensity of limb pain in the post-treatment period was significant (p=0.001). Quality of life also indicated a significant improvement (p=0.004). Changes in skin temperature and ankle/arm index demonstrated significant improvement (p≤0.005): skin temperature increased from 27.6°C to 31.2°C, the ankle/arm index inceased from 0.67 to 0.83 on average. Changes in objective and subjective measures correlated with each other. No worthening of symptoms, serious adverse events or complications were observed. Conclusion - The chemical denervation of the lumbar sympathetic ganglions with percutaneous application is a minimally invasive intervention, useful in outpatient care, which can be well tolerated by the patient without any significant side effect or complication. Its hyperaemic effect and the pain reduction of the leg can improve the quality of life of the patients.]