Papers by Sriram Yennurajalingam
Palliative and Supportive Care, 2014
Objective: Although &... more Objective: Although "fatigue" and "depression" are well-accepted clinical terms in the English language, they are ill defined in many other languages, including Portuguese. We aimed to investigate the most appropriate words to describe cancer-related fatigue (CRF) and depression in Brazilian cancer patients. Method: The interviewers read to patients two clinical vignettes describing fatigued patients and two others describing depressed patients. Participants were asked to choose from among "fatigue," "tiredness," "weakness," "depression," and "sadness" the best and worst terms to explain the vignettes. In addition, they were administered an instrument containing numeric rating scales (NRSs), addressing common symptoms, including the aforementioned terms. Pearson correlation analysis and accuracy diagnostic tests were conducted using the Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment of Cancer Treatment-Fatigue (FACIT-F) as references. Results: Among the 80 participants, 40% reported that the best term to explain the concept of CRF was "tiredness," and 59% chose…
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The oncologist, 2014
Cancer pain management guidelines recommend initial treatment with intermediate-strength analgesi... more Cancer pain management guidelines recommend initial treatment with intermediate-strength analgesics such as hydrocodone and subsequent escalation to stronger opioids such as morphine. There are no published studies on the process of opioid rotation (OR) from hydrocodone to strong opioids in cancer patients. Our aim was to determine the opioid rotation ratio (ORR) of hydrocodone to morphine equivalent daily dose (MEDD) in cancer outpatients. We reviewed the records of consecutive patient visits at our supportive care center in 2011-2012 for OR from hydrocodone to stronger opioids. Data regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and MEDD were collected from patients who returned for follow-up within 6 weeks. Linear regression analysis was used to estimate the ORR between hydrocodone and MEDD. Successful OR was defined as 2-point or 30% reduction in the pain score and continuation of the new opioid at follow-up. Overall, 170 patients underwent OR from hydrocodone...
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The oncologist, 2014
Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poi... more Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our objective was to determine the patterns of storage, utilization, and disposal of opioids among cancer outpatients. We surveyed 300 adult cancer outpatients receiving opioids in our supportive care center and collected information regarding opioid use, storage, and disposal, along with scores on the CAGE (cut down, annoyed, guilty, eye-opener) alcoholism screening questionnaire. Unsafe use was defined as sharing or losing opioids; unsafe storage was defined as storing opioids in plain sight. The median age was 57 years. CAGE was positive in 58 of 300 patients (19%), and 26 (9%) had a history of illicit drug use. Fifty-six (19%) stored opioids in plain sight, 208 (69%) kept opioids hidden but unlocked, and only 28 (9%) locked their opioids. CAGE-positive patients (p = .007) and those with a history of illicit drug use (p = .0002) or smoking (p = .03) were more likely to lock th...
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Palliative Medicine, 2013
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Journal of Pain and Symptom Management, 2014
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Journal of Pain and Symptom Management, 2013
Understanding cancer patients&amp... more Understanding cancer patients' preferences in decisional roles is important in providing quality care and ensuring patient satisfaction. There is a lack of evidence on decisional control preferences (DCPs) of Hispanic Americans, the fastest growing population in the U.S. The primary aims of this study were to describe DCPs of Hispanics with advanced cancer in the U.S. (HUSs) and compare the frequency of passive DCPs in this population with that of Hispanics with advanced cancer in Latin America (HLAs). We conducted a prospective survey of patients with advanced cancer referred to outpatient palliative care clinics in the U.S., Chile, Argentina, and Guatemala. Information was collected on sociodemographic variables, Karnofsky Performance Scale scores, acculturation (Marin Acculturation Assessment Tool), and DCP (Control Preference Scale). Chi-square tests were used to determine the differences in DCPs between HUSs and HLAs. A total of 387 patients were surveyed: 91 in the U.S., 100 in Chile, 94 in Guatemala, and 99 in Argentina. The median age of HUSs was 56 years, 59% were female, and the median Karnofsky Performance Scale score was 60; the corresponding values for HLAs were 60 years, 60%, and 80. HLAs used passive DCP strategies significantly more frequently than HUSs did with regard to the involvement of the family (24% vs. 10%; P=0.009) or the physician (35% vs. 16%; P<0.001), even after age and education were controlled for. Eighty-three percent of HUSs and 82% of HLAs preferred family involvement in decision making (P=non-significant). No significant differences were found in DCPs between poorly and highly acculturated HUSs (P=0.91). HUSs had more active DCPs than HLAs did. Among HUSs, acculturation did not seem to play a role in DCP determination. Our findings confirm the importance of family participation for both HUSs and HLAs. However, HUSs were less likely to want family members to make decisions on their behalf.
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Annals of palliative medicine, 2012
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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 20, 2014
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JAMA, Jan 17, 2007
Fatigue is the most common chronic symptom associated with cancer and other chronic progressive d... more Fatigue is the most common chronic symptom associated with cancer and other chronic progressive diseases. The assessment and treatment of fatigue at or near the end of life can be complex. Some of the challenges include its subjective nature, with great variability in its source, how it is expressed, and how it is perceived, requiring treatment to be based on patient report of frequency and severity; its multidimensional character; and the limited understanding of its pathophysiology. Using the case of an 82-year-old retired nurse with fatigue that could be explained by a number of concurrent conditions, including anemia, weight loss, depression and isolation, dyspnea, deconditioning, and medications, the authors illustrate the clinical approach to assess and treat fatigue at the end of life.
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Supportive cancer therapy, 2004
Pain and other symptoms of advanced cancer are not treated effectively yet. This review of the li... more Pain and other symptoms of advanced cancer are not treated effectively yet. This review of the literature discusses the needs and latest research findings about pain symptom assessment and management in palliative care. Pain assessment scores should not be followed blindly by a rigid therapeutic regimen. Instead, the health care provider should carefully consider the wide spectrum of possible underlying pain mechanisms. Unidimensional pain rating scales will not detect the impact of affective dimensions on pain expression as accurately as multidimensional rating scales that include various symptoms. Besides assessment tools like numeric rating scales or visual analogue scales, tools now frequently used in the daily clinical setting include the Edmonton Symptom Assessment System, the Mini Mental State Examination, and the CAGE questionnaire (Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers). Recent developments and findings in cancer pain management are illustrat...
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Current opinion in supportive and palliative care, 2014
Although corticosteroids are frequently used to palliate cancer-related symptoms, limited publish... more Although corticosteroids are frequently used to palliate cancer-related symptoms, limited published studies are available. This review summarizes recent literature on the impact of corticosteroids on fatigue, its related symptoms, and the role of 'corticosteroid rotation' in improving the corticosteroid-related side-effects. Only two placebo-controlled double-blinded randomized studies on corticosteroid for symptoms that met the inclusion criteria were published recently, despite the criteria being extended beyond 2012 and 2013. These two studies confirm the preliminary data that corticosteroids significantly improve cancer-related fatigue and anorexia with no significant side-effects. However, these studies were of short duration. Long-term use of corticosteroids is not recommended at this time because of the risk of debilitating side-effects and no evidence of its long-term benefits. Recent studies also suggest the possible role of corticosteroid rotation or switching simi...
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Cancer journal (Sudbury, Mass.)
Cancer-related fatigue (CRF) is the most common and debilitating symptom in patients with cancer.... more Cancer-related fatigue (CRF) is the most common and debilitating symptom in patients with cancer. Currently, there are very limited pharmacological interventions to effectively treat CRF. In this article, the authors review various pharmacological interventions for CRF and propose future direction for further research. Methylphenidate is the most studied pharmacological agent for the treatment of CRF. Various pharmacological studies have suggested benefit of corticosteroids, especially in terminally ill patients for a short period. However, recent systematic reviews, meta-analyses, and guidelines recommend caution to using pharmacological agents for CRF as evidence points the use of psychostimulants only in patients with moderate to severe fatigue with advanced cancer or those receiving active cancer therapy, with no evidence in their use in cancer patients who have completed active cancer therapy. Further research is needed.
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Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 10, 2010
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Palliative and Supportive Care, 2014
Objective: Although &... more Objective: Although "fatigue" and "depression" are well-accepted clinical terms in the English language, they are ill defined in many other languages, including Portuguese. We aimed to investigate the most appropriate words to describe cancer-related fatigue (CRF) and depression in Brazilian cancer patients. Method: The interviewers read to patients two clinical vignettes describing fatigued patients and two others describing depressed patients. Participants were asked to choose from among "fatigue," "tiredness," "weakness," "depression," and "sadness" the best and worst terms to explain the vignettes. In addition, they were administered an instrument containing numeric rating scales (NRSs), addressing common symptoms, including the aforementioned terms. Pearson correlation analysis and accuracy diagnostic tests were conducted using the Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment of Cancer Treatment-Fatigue (FACIT-F) as references. Results: Among the 80 participants, 40% reported that the best term to explain the concept of CRF was "tiredness," and 59% chose "sadness" as the best descriptor of depression. Regarding diagnostic accuracy, the areas under the curve (AUCs) for…
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Journal of Pain and Symptom Management, 2015
There is limited literature on characteristics of telephone triage programs and the nature of int... more There is limited literature on characteristics of telephone triage programs and the nature of interventions in palliative care. Our aim was to determine frequency and type of care provided by a Supportive Care Center Telephone Triaging Program (SCCTP) in advanced cancer patients (ACPs). Electronic medical records were reviewed of 400 consecutive ACPs referred to palliative care at a comprehensive cancer center and given access to the SCCTP: 200 from the outpatient Supportive Care Center (OP) and 200 from inpatient Palliative Care (IP) given access after discharge. We reviewed call frequency, type, reason and outcomes including pain and other symptoms (Edmonton Symptom Assessment Scale [ESAS] and Memorial Delirium Assessment Scale [MDAS]) associated with utilization of the SCCTP. A total of 375 patients were evaluable. One hundred fifteen of 400 patients (29%) utilized the SCCTP: 96 OPs (83%) used the SCCTP vs. only 19 IPs (17%) (P<0.001). The most common reasons for calls were pain (24%), pain medication refills (24%) and counseling (12%). For 115 phone calls, 43% (145/340) of recommendations were regarding care at home and 56% were regarding opioids. Patients who used the SCCTP had worse pain (P=0.006), fatigue (P=0.045), depression (P=0.041), and well-being (P=0.015) and better MDAS scores (P=0.014) compared to non-users. OPs had a higher prevalence of symptom distress (P=0.013), depression (P<0.001), anxiety (P <0.01) and insomnia scores (P=0.001); MDAS scores were significantly higher in IPs (P<0.001). In this study, we found that overall utilization of the SCCTP by ACPs referred to palliative care was relatively low at 28.7%. The use of the SCCTP was particularly poor among the IPs upon discharge. Patients who utilized SCCTP had worse pain, fatigue, depression, and well-being scores and better delirium scores.
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The oncologist, 2014
Cancer pain management guidelines recommend initial treatment with intermediate-strength analgesi... more Cancer pain management guidelines recommend initial treatment with intermediate-strength analgesics such as hydrocodone and subsequent escalation to stronger opioids such as morphine. There are no published studies on the process of opioid rotation (OR) from hydrocodone to strong opioids in cancer patients. Our aim was to determine the opioid rotation ratio (ORR) of hydrocodone to morphine equivalent daily dose (MEDD) in cancer outpatients. We reviewed the records of consecutive patient visits at our supportive care center in 2011-2012 for OR from hydrocodone to stronger opioids. Data regarding demographics, Edmonton Symptom Assessment Scale (ESAS), and MEDD were collected from patients who returned for follow-up within 6 weeks. Linear regression analysis was used to estimate the ORR between hydrocodone and MEDD. Successful OR was defined as 2-point or 30% reduction in the pain score and continuation of the new opioid at follow-up. Overall, 170 patients underwent OR from hydrocodone...
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The oncologist, 2014
Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poi... more Improper storage, use, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our objective was to determine the patterns of storage, utilization, and disposal of opioids among cancer outpatients. We surveyed 300 adult cancer outpatients receiving opioids in our supportive care center and collected information regarding opioid use, storage, and disposal, along with scores on the CAGE (cut down, annoyed, guilty, eye-opener) alcoholism screening questionnaire. Unsafe use was defined as sharing or losing opioids; unsafe storage was defined as storing opioids in plain sight. The median age was 57 years. CAGE was positive in 58 of 300 patients (19%), and 26 (9%) had a history of illicit drug use. Fifty-six (19%) stored opioids in plain sight, 208 (69%) kept opioids hidden but unlocked, and only 28 (9%) locked their opioids. CAGE-positive patients (p = .007) and those with a history of illicit drug use (p = .0002) or smoking (p = .03) were more likely to lock th...
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Palliative and Supportive Care, 2013
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Papers by Sriram Yennurajalingam