Paul Howard

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Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a retrospective cohort study - British Journal of Cancer

Paul Howard

@paulhoward.bsky.social

Important study examining effect of ethnicity on UK ED attendance outcomes in last 3 months of life.
Found white patients received more analgesia and were admitted less often.

www.nature.com/articles/s41...

British Journal of Cancer - Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a...

Reposted by: Paul Howard

Mark Hazelwood

@palliativescot.bsky.social

@drkathrynmannix.bsky.social Edinburgh is famously accessible from the NE of England, & we are always delighted to welcome palliative care people across the border to our conferences. We have a great line up this year, closer & cheaper than London. www.palliativecarescotland.org.uk/content/annu...

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Paul Howard

@paulhoward.bsky.social

Database studies are prone to streaming; i.e. since apixaban is known to carry a lower bleeding risk, more likely to select it if higher bleed risk - can only control for coded risk factors, so some risk factors missed
So it's interesting that they still found apixaban's non-major bleed risk lower

Comparative safety and effectiveness of apixaban and rivaroxaban for treatment of cancer-associated venous thromboembolism: A retrospective cohort study

Paul Howard

@paulhoward.bsky.social

"In cancer-associated VTE, apixaban was associated with similar risks of recurrent VTE and major bleeding, and a lower risk of clinically relevant non-major bleeding compared with rivaroxaban"

journals.plos.org/plosmedicine...

Jingjing Sun and colleagues compare the risk of recurrent venous thromboembolism, major bleeding, and clinically relevant non-major bleeding among individuals with cancer-associated venous thromboembo...

journals.plos.org

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Hypodermoclysis for the administration of fluids and narcotic analgesics in patients with advanced cancer - PubMed

Paul Howard

@paulhoward.bsky.social

I agree; in UK hospitals I see administration of fluids and drugs delayed for hours in those with difficult veins.
SC would often be a far faster option: fluids, many antibiotics, PPIs, TXA, metoprolol, corticosteroids; the list of drugs given SC grows yearly yet remains little used in UK hospitals

Eduardo Bruera @brueraeduardo.bsky.social · 11d

In 58 advanced cancer patients, hypodermoclysis provided safe, effective hydration for up to 14 days, with minimal local toxicity and frequent co-administration of opioids and potassium. And 30 ys later still not done in American hospices and hospitals

pubmed.ncbi.nlm.nih.gov/2384700/

Fifty-eight consecutive patients with advanced cancer who required parenteral hydration were treated with hypodermoclysis. A solution of two-thirds 5% dextrose and one-third saline was used in all cas...

pubmed.ncbi.nlm.nih.gov

a picture of a mosquito killer hanging from the ceiling with the caption i can 't help it it 's so beautiful

Reposted by: Paul Howard

c0nc0rdance

@c0nc0rdance.bsky.social

The idiom "like a moth to the flame" dates to at least the 12th century, to Persian love poem "Layla and Majnun". Shakespeare references it in "Merchant of Venice."

But here's the thing. Moths DON'T fly to flames. And we're just now understanding that.

Let's talk about dorsal light response.

Alt: a picture of a mosquito killer hanging from the ceiling with the caption i can 't help it it 's so beautiful

media.tenor.com

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Reposted by: Paul Howard

Eduardo Bruera

@brueraeduardo.bsky.social

In 58 advanced cancer patients, hypodermoclysis provided safe, effective hydration for up to 14 days, with minimal local toxicity and frequent co-administration of opioids and potassium. And 30 ys later still not done in American hospices and hospitals

pubmed.ncbi.nlm.nih.gov/2384700/

Hypodermoclysis for the administration of fluids and narcotic analgesics in patients with advanced cancer - PubMed

Fifty-eight consecutive patients with advanced cancer who required parenteral hydration were treated with hypodermoclysis. A solution of two-thirds 5% dextrose and one-third saline was used in all cas...

pubmed.ncbi.nlm.nih.gov

Paul Howard

@paulhoward.bsky.social

🙋‍♂️

Paul Howard

@paulhoward.bsky.social

Points I learned were:
1."Normal" levels don't exclude deficiency. NICE suggest MMA if B12 180-350 (indeterminate) but our local haem suggests go straight to trial of Rx (MMA also problematic)
2.Many need maintenance more often than 2-3 monthly, so if Sx recur before next injection, shorten interval

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Paul Howard

@paulhoward.bsky.social

This is a really key point.
E.g studies of "high dose (1mg) B12" are uninterpretable because they use blood levels not symptoms as an outcome (oral replacement can increase blood levels without adequately correcting deficiency).

Rachel Howard @rachel-h-iow.bsky.social · 19d

Because the serum B12 can give surprisingly high levels of false positives (unnecessary painful injections) and false negatives (dangerous symptom progression due to missed diagnosis) neither clinical treatment nor scientific study should rely on blood test results alone (but both usually do).

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Paul Howard

@paulhoward.bsky.social

Hi Calum. Yes, partly that. Partly an "adjusted calcium" type issue (ie B12 levels generally include haptocorrin-bound B12 which is inactive and gets excreted; haptocorrin increases in cancer); partly, like iron, your handling of B12 is altered in inflammation; and partly it's poorly understood

Paul Howard

@paulhoward.bsky.social

B12 deficiency is also really relevant in palliation. I'm seeing people with fatigue and apparently "normal" B12 levels respond really well to SC B12 replacement (i.e. fatigue in advanced illness but in the absence of cachexia/inflammation). So this thread is really interesting

Rachel Howard @rachel-h-iow.bsky.social · 19d

This afternoon at CluB12 a fascinating overview of the history of B12 deficiency/pernicious anaemia from the amazing Ebba Nexo who has spent her whole career working in this field.

Reposted by: Paul Howard

Rachel Howard

@rachel-h-iow.bsky.social

Because the serum B12 can give surprisingly high levels of false positives (unnecessary painful injections) and false negatives (dangerous symptom progression due to missed diagnosis) neither clinical treatment nor scientific study should rely on blood test results alone (but both usually do).

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Reposted by: Paul Howard

Rachel Howard

@rachel-h-iow.bsky.social

This afternoon at CluB12 a fascinating overview of the history of B12 deficiency/pernicious anaemia from the amazing Ebba Nexo who has spent her whole career working in this field.

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Cancer Cachexia: ASCO Guideline Rapid Recommendation Update

Paul Howard

@paulhoward.bsky.social

Follows inclusion of olanzapine in ASCO's recommendations in 2023 after another "positive" RCT:
doi.org/10.1200/JCO....

ASCO Rapid Recommendations Updates highlight revisions to select ASCO guideline recommendations as a response to the emergence of new and practice-changing data. The rapid updates are supported by an ...

doi.org

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Autism is on the rise: what’s really behind the increase?

Paul Howard

@paulhoward.bsky.social

Here, an RCT showing olanzapine improves cancer-related loss of appetite. That said, like other current appetite stimulant options, it's improving enjoyment of food, but not muscle/strength (here, handgrip strength decreased)

dx.doi.org/10.6004/jncc...

dx.doi.org

1 1 4

Reposted by: Paul Howard

Pharmacopalliation

@pharmacopalliation.bsky.social

💡 Midazolam is actually water-soluble in its vial, but becomes lipid-soluble once it enters the body.

That’s unusual for a benzodiazepine. The trick lies in its imidazole ring 👇

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Reposted by: Paul Howard

Magdalena Skipper

@magdalenaskipper.bsky.social

“We don’t see an epidemic of autism, but we see an ‘epidemic’ of diagnoses”

A fresh journalistic look at the rise in autism that brings together perspectives from the researchers & the autism community
🧪 #MedSky

@nature.com by @helenpearson.bsky.social

www.nature.com/articles/d41...

RFK Jr has vowed to find out what’s responsible, but scientists say he is ignoring answers from decades of research.

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Reposted by: Paul Howard

Pharmacopalliation

@pharmacopalliation.bsky.social

💊💊ALFENTANIL💊💊
Alfentanil’s pKa ~6.5, much lower than fentanyl (~8.4) or morphine (~8.0)

At physiologic pH (7.4), ~90% of alfentanil exists in the unionised, lipid-soluble form → crosses the blood–brain barrier very rapidly

This explains why alfentanil has the fastest onset of action of any opioid

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Paul Howard

@paulhoward.bsky.social

Hi Sarah, you could get the same outcome with a series of 200mg IM loading doses. I think the key point is that if, say, an initial total of 600mg is sufficient, then the maintenance dose needed is very much less than 800mg/day; or perhaps not necessary at all

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Short subcutaneous infusions for symptom control in palliative medicine - PubMed

Paul Howard

@paulhoward.bsky.social

The initial 600mg loading can be given in 50mL of NaCl as a single short subcut infusion. In this series, 85% responded to the first dose, despite being used in those with agitation refractory to multiple other drugs (midazolam, levomepromazine, clonidine)
pubmed.ncbi.nlm.nih.gov/37798082/

SSCIs appear to be a promising additional option for administering medicines that are too irritant or large in volume for SC bolus injection. For medications with longer half-lives (eg, phenobarbital,...

pubmed.ncbi.nlm.nih.gov

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Novel staggered loading of phenobarbitone for refractory seizures and agitation at the end of life

Paul Howard

@paulhoward.bsky.social

Really useful paper. Traditional dosing strategies (200mg IM loading, followed by 800-1200mg/day) don't reflect its half-life. Typical loading doses of around 600mg may not need any follow-on regular dose (or a very-much-less than 800mg/day dose if used)

Pallmedpro @pallmedpro.bsky.social · Aug 20

Did you know, that the half life of phenobarbitone is an average of 4 days?! The way we use it in palliative care needs to be proportionate, specialist-led, and congruent with known pharmacokinetics. @bmj.com Supportive and Palliative Care has more: spcare.bmj.com/content/earl... #palliativecare

Background Seizures and agitation are distressing symptoms commonly encountered at the end of life and may require treatment with phenobarbitone when standard therapies fail. Current phenobarbitone do...

spcare.bmj.com

1 1 2

Reposted by: Paul Howard

Pallmedpro

@pallmedpro.bsky.social

Did you know, that the half life of phenobarbitone is an average of 4 days?! The way we use it in palliative care needs to be proportionate, specialist-led, and congruent with known pharmacokinetics. @bmj.com Supportive and Palliative Care has more: spcare.bmj.com/content/earl... #palliativecare

Novel staggered loading of phenobarbitone for refractory seizures and agitation at the end of life

Background Seizures and agitation are distressing symptoms commonly encountered at the end of life and may require treatment with phenobarbitone when standard therapies fail. Current phenobarbitone do...

spcare.bmj.com

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Reposted by: Paul Howard

John Ross

@johnrossmd.bsky.social

“I always told myself the stress of dealing with insurance was worse than the cancer”: patient perspectives on the Kafkaesque nightmare of having cancer in America

Patient Perspectives on Prior Authorization for Cancer Care

This qualitative study characterizes the perspectives of patients with cancer regarding their experience with prior authorization for cancer care.

jamanetwork.com

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Reposted by: Paul Howard

Dr Ben Bowers

@drbenbowers.bsky.social

Reframing resilience in community healthcare. Our latest piece in BJCN
magonlinelibrary.com/doi/abs/10.1...

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Paul Howard

@paulhoward.bsky.social

Elinzanetant, a dual neurokinin 1 and 3 receptor (NK1/NK3) antagonist licenced in UK for peri-menopausal Sx, also now trialed for hot flushes due to endocrine therapy for breastfeeding cancer. Similar trial recruiting for fezolinetant (NK3 antagonist).

www.nejm.org/doi/abs/10.1...

www.nejm.org

Reposted by: Paul Howard, Clare Bambra

Donna Wakefield

@donnawakefield.bsky.social

📣Published TODAY 📖
It means so much to me to share our paper on #PalliativeCare & #EoLC for people with pleural #Mesothelioma 🫁 in @palliativemedj.bsky.social

Thank you to @mesouk.bsky.social for funding this research

Please share 🔁
journals.sagepub.com/doi/10.1177/...

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Comparative efficacy of memantine and vitamin C in postoperative pain management: a randomized clinical trial

Paul Howard

@paulhoward.bsky.social

A small RCT (n=34) comparing memantine with an active placebo finding a reduction in both pain and PRN opioid consumption. Memantine’s of analgesic interest because of it’s NMDA action (i.e. ketamine-like)

doi.org/10.1080/1758...

Acute postoperative pain affects most surgical patients, often delaying recovery. Memantine (Namenda®), an N-methyl-D-aspartate (NMDA) receptor antagonist, offers potential for effective pain relie...

doi.org

2 1

Reposted by: Paul Howard

Prof Sheena Cruickshank

@sheencr.bsky.social

New evidence just out shows definitive link between mechanisms driving cancer in smoking with those caused by pollution. Common mechanisms included mutations in the TP53 and EGFR genes 🧪

The mutagenic forces shaping the genomes of lung cancer in never smokers - Nature

An analysis of data from the Sherlock-Lung study provides insight into the mutational processes that contribute to lung cancer in never smokers, and looks at the possible role of factors such as ...