Practice review: Evidence-based and effective management of fatigue in patients with advanced cancer

Background: Fatigue affects most patients living with advanced cancer and is a symptom that healthcare professionals can find difficult to manage. Aim: To provide healthcare professionals with a pragmatic overview of approaches to management of fatigue in patients with advanced cancer that are commonly recommended by guidelines and to evaluate evidence underpinning them. Design: Scoping review methodology was used to determine the strength of evidence supporting use of interventions recommended in management of fatigue in patients with advanced cancer. Data sources: National or international guidelines were examined if they described the management of fatigue in adult cancer patients and were written within the last 6 years (2015–2021) in English. The Cochrane Database of Systematic Reviews (January 2011–December 2021) was searched for ‘cancer’ AND ‘fatigue’ in title, abstract or keywords. A PubMed search was also made. Results: Evidence indicates physical exercise interventions are effective and patients may benefit from energy conservation tactics. Evidence does not support use of psychostimulants such as methylphenidate. Limited data were found on efficacy of corticosteroids, psychological interventions, nutritional intervention, sleep optimization or complementary therapies for management of fatigue in advanced cancer. Conclusion: We recommend regular assessment, review and acknowledgement of the impact of fatigue. Exercise and energy conservation should be considered. Pharmacological interventions are not endorsed as a routine approach. Many interventions currently recommended by guidelines are not supported by a robust evidence base and further research on their efficacy is required.

Repeated standing back extension exercise: Influence on muscle shear modulus change after lumbodorsal muscle fatigue

BACKGROUND: In low back pain, multifidus muscle fibers reportedly exhibit increased stiffness. Low back pain was associated with lumbodorsal muscle fatigue. There is no report of using shear modulus to verify the mechanism of an immediate effect of exercise on low back pain. Here, temporary lumbodorsal muscle fatigue was created, simulating fatigue-related nonspecific low back pain. OBJECTIVE: To assess the effect of standing back extension exercise on fatigued lumbodorsal muscle based on the results of multifidus muscle elasticity measured using shear wave elastography. METHODS: Thirty-three healthy subjects were randomly divided into three groups. The subjects performed the Biering-Sorensen test as the fatigue-task of the lumbodorsal muscle before the standing back extension exercise. The fatigue-exercise group exercised five sets after completing the fatigue-task. The fatigue-non-exercise group remained standing for the same duration as the fatigue-exercise group without doing the exercise after the fatigue-task. The non-fatigue-exercise group exercised five sets of without performing the fatigue-task. As intra-group and inter-group factors, the shear modulus of the multifidus muscle was compared before and after the exercise. RESULTS: The shear modulus of the multifidus muscle after the standing back extension exercise was significantly lower in the fatigue-exercise group, and no significant decrease was observed in the fatigue-non-exercise and non-fatigue-exercise group. CONCLUSIONS: The standing back extension exercise improved the shear modulus of the fatigued multifidus muscle. Therefore, it was suggested that the change in the elasticity of fatigued muscle might lead to the prevention of low back pain caused by muscle fatigue.

Exercise-induced muscle damage: multi-parametric MRI quantitative assessment

Background To explore the value of magnetic resonance quantitative analysis using diffusion tensor imaging, T2 mapping, and intravoxel incoherent motion in the evaluation of eccentric exercise-induced muscle damage and to compare the effects of various eccentric exercise modes at different time points in rats. Methods A total of 174 Sprague-Dawley male rats were randomly divided into five groups: control, once-only exercise, continuous exercise, intermittent exercise, and once-fatigue exercise groups. Each experimental group was divided into seven time-subgroups: 0.5 h, 24 h, 48 h, 72 h, 96 h, 120 h and 168 h after exercise. The quadriceps femoris muscles were then scanned using magnetic resonance imaging. The apparent diffusion coefficient and fractional anisotropy values of diffusion tensor imaging, T2 values of T2 mapping, D and D* values of intravoxel incoherent motion and optical density values of desmin were measured. Associations among different eccentric exercise programmes, magnetic resonance imaging findings, and histopathological results were evaluated. Dunnett’s test, two-way repeated measures analysis of variance, and Pearson correlation analysis were used for statistical analysis. Results Diffusion tensor imaging showed that the number of muscle fibre bundles decreased to varying degrees with different time points and eccentric exercises. Apparent diffusion coefficient values of the exercise groups showed a trend that first increased and then decreased, the opposite of fractional anisotropy. The specimens in all eccentric exercise programmes showed high signal T2 values after exercise, the highest among which was in the once-fatigue exercise group. D and D* in the experimental groups were significantly higher than those in the control group at 0.5–48 h after exercise. The apparent diffusion coefficient, fractional anisotropy, T2, D and D* values correlated with the optical density values of desmin. Conclusions Diffusion tensor imaging, T2 mapping, and intravoxel incoherent motion technology accurately reflect the degree of skeletal muscle damage and recovery associated with eccentric exercise. The degree of muscle damage was the lowest in the continuous exercise group and the highest in the once-fatigue exercise group, which may provide more information and guidance for the formulation of physical and athletic training programmes.

The importance of pharmacotherapeutic follow-up in patients with heart failure

Heart failure is a chronic disease that compromises the patient's quality of life, due to its symptoms, such as: tiredness/fatigue, exercise intolerance, orthopnea, paroxysmal nocturnal dyspnea. The aim of the present study was to intervene and assist in the treatment of Heart Failure patient with pharmacological and non-pharmacological approaches in order to improve the quality of life and patient compliance regarding the existing disease. Pharmaceutical consultations were carried out over a seven-month period with a patient that suffers from Heart Failure, resident of Umuarama-PR, treated at home. The SOAP method was adopted for the registration of consultations for later analysis, and the measurement of blood pressure was performed by the patient, using the HBPM method. For the analysis of interactions, the Micromedex database and the patient’s package leaflet were used.The patient had a significant decrease in his BP with the follow-up; however, he showed resistance to going to the doctor. After some guidance, the patient agreed to go to the consultation and he was diagnosed with Renal Failure and Prostatic Hyperplasia. It is concluded that pharmaceutical care can be an effective alternative in obtaining better clinical results and helps to improve the patient's quality of life, since it can provide awareness of their health status and the need for the correct use of medications, making the most effective and safe treatment.

SAT0052 THERAPEUTIC STRATEGIES IN DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS: PRELIMINARY RESULTS OF A SYSTEMATIC LITERATURE REVIEW INFORMING THE 2020 EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background:Rheumatoid arthritis (RA) patients treated according to European League Against Rheumatism (EULAR) recommendations failing ≥2 biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) with a different mode of action who still have complaints which may be suggestive of active disease may be defined as suffering from ‘difficult-to-treat RA’. Management recommendations for RA focus predominantly on the earlier phases of the disease and specific recommendations for difficult-to-treat RA patients are currently lacking.1Objectives:To systematically summarise evidence in the literature on pharmacological and non-pharmacological therapeutic strategies for difficult-to-treat RA patients, informing the 2020 EULAR recommendations for the management of difficult-to-treat RA.Methods:A systematic literature review (SLR) was performed: PubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised.Results:Thirty articles were selected for therapeutic strategies in patients with limited DMARD options due to contraindications, 73 for patients in whom previous b/tsDMARDs were not effective (‘true refractory RA’), and 51 for patients with predominantly non-inflammatory complaints. For patients with limited DMARD options, limited evidence was found on effective DMARD options for patients with concomitant obesity, and on safe DMARD options for patients with concomitant hepatitis B and C. In patients who failed ≥2 bDMARDs, tocilizumab, tofacitinib, baricitinib, upadacitinib and filgotinib were found to be more effective than placebo, but evidence was insufficient to prioritise. In patients who failed ≥1 bDMARD, there was a tendency of non-tumour necrosis factor inhibitor (TNFi) bDMARDs to be more effective than TNFi (Figure 1). Generally, b/tsDMARDs become less effective when patients failed more bDMARDs, this tendency was not clear for upadacitinib and filgotinib (Figure 2). In patients with predominantly non-inflammatory complaints (mainly function, pain and fatigue), exercise, education, psychological and self-management interventions were found to be of additional benefit.Conclusion:This SLR underscores the scarcity of evidence on the optimal treatment of difficult-to-treat RA patients. As difficult-to-treat RA is a newly defined disease state, all evidence is to an extent indirect. Several b/tsDMARDs were found to be effective in patients who failed ≥2 bDMARDs and generally effectiveness decreased with a higher number of failed bDMARDs. Additionally, a beneficial effect of non-pharmacological interventions was found on non-inflammatory complaints.References:[1] Smolen JSet al. Ann Rheum Dis2020. Epub ahead of print.Disclosure of Interests:Nadia M. T. Roodenrijs: None declared, Attila Hamar: None declared, Melinda Kedves: None declared, György Nagy: None declared, Jacob M. van Laar Grant/research support from: MSD, Genentech, Consultant of: MSD, Roche, Pfizer, Eli Lilly, BMS, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead Sciences, Inc., Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma; Director of Imaging Rheumatology BV, Paco Welsing: None declared

P274 Association of self-reported symptoms and behaviour in axSpA: initial analyses from the Project Nightingale study

Background Axial spondyloarthritis (axSpA) is a chronic inflammatory disease primarily affecting the spine and sacroiliac joints, characterised by fluctuating periods of flare and remission. Management is based on patient-reported symptoms and outcome measures collected at follow-up appointments which may be subject to recall bias. Smartphone technologies for monitoring disease symptoms provide an opportunity to gain a more complete understanding of disease burden and symptom patterns and may facilitate optimisation and personalisation of axSpA management. Methods Patients with axSpA attending the Royal National Hospital for Rheumatic Diseases in Bath were invited to participate in the study. Through the uMotif symptom tracking app, patients were sent daily reminders to log pain, fatigue, sleep, recommended exercise, mood and stress using 5-point Likert scales (higher scores indicating better outcomes eg. No pain=5), in addition to optional variables such as screen time, caffeine intake and menstrual cycle. For each patient, at each time-point, Spearman rank correlation coefficients were used to evaluate inter-variable correlations. Lagged variables were used to assess correlations with variables from the previous day (variable-1). Results Between 05/04/18 and 08/03/19, 174 patients consented for research and logged a mean of 99.73 (SD = 99.97) days of data (range=1 - 323 days). Significant correlations were identified between uMotif variables (Table 1), including pain and fatigue; mood and stress; hot flushes and fatigue/pain; confidence in self-management and mood/pain; smoking and pain/fatigue; exercise and sleep; exercise and mood - supporting existing evidence regarding exercise implementation in axSpA. Conclusion These findings demonstrate relationships between a variety of patient-reported symptoms, including variables that to our knowledge, have not yet been explored in axSpA. In future research, it will be important to determine whether there is a chronological pattern within an individual or combination of variables that could predict a flare. Greater understanding of axSpA disease patterns and identification of the optimal timing of intervention to ameliorate these symptoms may ultimately reduce flare frequency, duration and intensity, and greatly improve quality of life for patients with axSpA. Disclosures R. Barnett None. S. Ng None. S.L. Jones None. M. Young None. R. Sengupta None.

Experimental Study on Biomedical Signal Acquisition of Sports Fatigue

To explore the biomedical signal acquisition of sports fatigue, the Pclab-UE biomedical signal acquisition and processing system is used to collect and process heart rate variability (HRV) automatically after quiet and fatigue exercise. In the meanwhile, the experimental data are analyzed. The heart rate variability of the subjects is recorded, aiming to provide experimental evidence for the future application of HRV in the diagnosis of exercise fatigue. Moreover, it also provides a noninvasive diagnostic index for exercise fatigue and exercise training practice. The research results showed that, the HRV values in the sub-maximal exercise caused fatigue. The maximal exercise induced fatigue is significantly decreased and there are significant differences. As a result, it is summed up that we can use HRV as a quantitative analysis index for the diagnosis of sports fatigue.

Effectiveness of chest physiotherapy and pulmonary rehabilitation in patients with non-cystic fibrosis bronchiectasis: a narrative review

Respiratory physiotherapy and rehabilitation are important therapeutic options in non-cystic fibrosis bronchiectasis (NCFB). The aims of this review of clinical trials were to evaluate the safety and the effects on physiologic and clinical outcomes of airway clearance techniques (ACTs) and rehabilitation in NCFB patients, in comparison to usual care. The search was performed on March 2018 by using PubMed and PeDro databases. 33 studies were selected. The use of ACTs for NCFB were effective in increasing sputum volume although no benefit in quality of life (QoL) or pulmonary exacerbations were observed. There were no differences in effectiveness between the several techniques used. Humidification and saline inhalation were able to aid airway clearance. Hypertonic solution (HS) was more effective than isotonic solutions (IS) in improving expectoration and sputum viscosity. Pulmonary rehabilitation (PR) was found to be associated with short term benefits in exercise capacity, dyspnea and fatigue. Exercise training seems to improve quality of life and lower exacerbation rate, but long-term data are not available. Further studies are necessary to identify the most feasible long-term outcomes such as QoL and exacerbation rate.