搜索结果：Palliative medicine reports

Early palliative care can improve end-of-life outcomes, but referrals to palliative care specialists can be delayed in the primary care setting. This pilot study assessed the effect of a machine-learning algorithm on time to palliative care in a primary care population. Patients (aged ≥18 years) were eligible if they were empaneled with a primary care provider (PCP) from July 20, 2020, through May 30, 2021. The algorithm evaluated their health records and presented patients who were predicted to have the greatest need for palliative care. Records were then reviewed by palliative care specialists, and patients were randomized in a stepped-wedge fashion to have a referral notification sent to their PCPs if unmet palliative care needs were verified. Time-to-event outcomes were evaluated with Poisson regression models. Of the 127,080 patients evaluated, 934 had their health records presented for review. Some patients were repeatedly presented by the algorithm (total presentations: 1592). In the intervention arm, PCPs were prompted to order a palliative care consultation for 142 patients. The time to 0.1% of the population receiving a palliative care consultation was 60.9 days for the intervention arm versus 71.8 days for the control arm (probability of a shorter time with the intervention, 0.88). A machine-learning algorithm to identify palliative care needs was successfully integrated into a primary care practice. More work is needed to improve the workflow.

Ensuring a smooth transition from hospital cancer care to home palliative care remains a key challenge, while pharmacist involvement in pre-discharge conferences has traditionally been limited in Japan. We investigated whether coordination by the Board Certified Pharmacist in Palliative Pharmacy (BCPPP) could enhance the extent and quality of pharmacist participation. In this retrospective descriptive observational study, we examined pre-discharge conferences for patients with advanced cancer, pharmacist participation rates and level of involvement from hospital and community pharmacies, methods of medical narcotics administration, and the rates of short-term readmission from January 2018 to December 2024. The BCPPP-led coordination initiative was initiated in 2022, which comprises of identification of the patients requiring home palliative care, arranging the pre-discharge conferences, support for opioid pharmacotherapy, coaching ward pharmacists, and ensuring the continuity of pharmacotherapy after discharge. Outcomes were compared between periods before (2018-2021) and after the start of interventions by a certified pharmacist (2022-2024). A total of 110 pre-discharge conferences were conducted. The certified pharmacist in palliative pharmacy coordinated collaboration with medical social workers. Pharmacist participation in pre-discharge conferences significantly increased after the intervention (hospital: 9.3% vs. 80.0% [p < 0.01], community pharmacies: 5.3% vs. 54.3% [p < 0.01]). The proportion of pharmacist recommendations focused on discharge planning increased from 35.7% to 73.3% (p < 0.05). The two- and four-week readmission rates did not differ significantly before and after the intervention (two-week: 13.2% vs. 3.0%; four-week: 17.6% vs. 18.2%). Coordination by a certified pharmacist in palliative pharmacy increased pharmacist participation inside and outside the hospital and promoted more proactive involvement in palliative care during pre-discharge planning. Although short-term readmission rates did not significantly change, strengthened collaboration between hospital and community pharmacies may contribute to improved continuity of palliative care during the transition to home.

Self-report is the gold standard for assessing pain intensity, although the method of acquiring pain reports may influence the ratings obtained. Retrospective reports of pain intensity are often found to be elevated relative to daily diary reports, possibly due to recall bias and the influence of psychosocial factors on memory. In this study, we sought to examine differences between retrospective reporting of average pain intensity in the past week vs averaged daily diary reporting of pain intensity in a sample of adolescents with juvenile fibromyalgia (JFM). We also sought to determine the predictive effects of pain catastrophizing, functional disability, and depressive symptoms on discrepancies between retrospective and daily diary report. As part of a randomized controlled trial, 317 adolescents with JFM (Mage = 15.7, SD = 1.6, 88.4% female) completed daily diary and one-week retrospective pain intensity measures, the Children's Depression Inventory-2, Functional Disability Inventory, and Pain Catastrophizing Scale at baseline, post-treatment, and 3-month follow-up. We examined the predictive effects of psychosocial factors on mean differences between averaged daily and one-week retrospective reports of pain intensity. Retrospective reports of pain intensity were significantly higher than diary reports across time. A longitudinal multiple linear regression model showed that the magnitude of discrepancies between daily diary and retrospective reports was not significantly predicted by functional disability, depressive symptoms, or pain catastrophizing. These findings raise the possibility that other factors such as cognitive biases (eg, threat interpretation, saliency, recency bias) may play a larger role than psychosocial factors in explaining pain reporting discrepancies.

Refractory status epilepticus complicating hepatic encephalopathy poses unique palliative challenges as standard extubation protocols typically reduce or discontinue sedative infusions, risking immediate seizure recurrence and distress. We report a 53-year-old man with end-stage cirrhosis and hepatocellular carcinoma who developed hepatic encephalopathy and refractory status epilepticus precipitated by small bowel obstruction. Despite ammonia-lowering therapy and multiple antiseizure medications, seizures remained refractory. Electroencephalography confirmed status epilepticus despite escalating therapy. Given prohibitive surgical risk and poor prognosis, the multidisciplinary team and patient's family elected to withdraw life-sustaining treatments, requesting he not die with an endotracheal tube in place. He underwent palliative extubation while continuing propofol and midazolam infusions to suppress seizure activity and ensure comfort. He died peacefully without visible seizure activity. Although limited by a single patient, this case provides a practical example of a rarely described palliative strategy: continuing sedative infusions during palliative extubation to prevent agonal seizures in refractory status epilepticus.

Access to a palliative approach to care improves the quality of life of individuals with a serious illness and their families. This paper describes the development of a decision-support tool that identifies individuals receiving home care and long-term care services who could potentially benefit from a palliative approach to their care based on information available in interRAI assessments used in those sectors as part of regular practice. A consultative and iterative multi-phase approach was employed to develop the "Serious Illness Collaborative Action Plan" (or Serious Illness CAP), over an 18-month period. Criteria for triggering this CAP were established with 49 individuals across seven advisory groups; criteria were operationalized using items and measures available in interRAI instruments and tested using anonymized population-level data from home care (N&#x2009;=&#x2009;568,586) and LTC (N&#x2009;=&#x2009;35,713) sectors in three Canadian provinces were analyzed. The CAP is based on the presence of health instability and potentially modifiable exacerbating issues (i.e., severe/excruciating daily pain, moderate/severe mood problems, severe fatigue, self-reported loneliness or social isolation, and condition/disease that create instability in thinking, self-care, mood, or behaviour patterns). The CAP identifies three distinct groups: those at high priority for a palliative approach, those at moderate priority, and those who don't trigger the CAP. Among home care clients in Ontario, 42% triggered the CAP; 10% (n&#x2009;=&#x2009;57,025) at a high priority, and 32% (n&#x2009;=&#x2009;181,531) at a moderate priority. Within LTC homes in Nova Scotia and Saskatchewan, these equaled 12% (overall), 5.2% (n&#x2009;=&#x2009;1,858 as high priority) and 6.8% (n&#x2009;=&#x2009;2,411 as moderate priority). The development of this new CAP will help support clinicians in home care and LTC settings to engage in conversations and promote awareness of the benefits of a palliative approach to care for individuals with serious or life-limiting illness and their families.

Palliative sedation is used to relieve refractory suffering in terminally ill patients. Propofol, an intravenous anesthetic, may offer advantages due to its rapid onset and short half-life. To evaluate the role of propofol in palliative sedation, focusing on symptom control, sedation depth, survival time, safety, and ethical implications. Systematic review registered in PROSPERO (CRD42025643575; February 6, 2025). Scopus, MEDLINE, and Web of Science were searched for English-language studies (2005-2024) on propofol use in adult terminally ill patients. Studies comparing propofol with other sedatives or non-sedated controls were included; those involving anesthetic or intensive care settings were excluded. Risk of bias and certainty of evidence were assessed. Results were synthesized narratively. Ten non-randomized studies were included (observational, cross-sectional, cohort, case series, and before-and-after designs), mostly of moderate quality, conducted in Europe (n&#x2009;=&#x2009;7) involving 4072 patients (28,3% received palliative sedation), mainly with cancer. Symptom control was reported in 73%-100% of cases, target sedation depth was achieved in 52%-100%, although outcome definitions and measurement methods varied. Survival ranged from 19&#x2009;h to 38&#x2009;days. Propofol was used alone (n&#x2009;=&#x2009;4) or with other sedatives (n&#x2009;=&#x2009;6). Respiratory depression was the main safety concern. Ethical issues included absence of explicit consent and rare reports of life-shortening intent. Propofol may be considered as a rescue option in selected refractory cases managed by experienced teams; however, given the low to very low certainty of available evidence, findings should be interpreted cautiously and supported by institutional protocols and further prospective research.

We sought to analyze the effect of a palliative care intervention on quality of life (QoL) in patients with fibrotic interstitial lung disease (fILD). This was a prospective observational study including 14 patients with fILD treated with a bundle of care provided by multidisciplinary specialists in pain and palliative care, a psychologist, physical therapists, and a nutritionist, with all patients initiating 10 mg of morphine sulfate. Measurements at baseline, 30 days, and 90 days included cough, dyspnea, pain, tiredness, nausea, depression, anxiety, sleepiness, appetite, and difficulty sleeping. QoL was recorded using the modified St. George's Respiratory Questionnaire (SGRQ-1). Change over time in each endpoint was analyzed. Baseline assessment reflected an impaired QoL (median SGRQ-1, 91 points). All symptom scores improved at 90 days, with a statistically significant and clinically meaningful 20-point decrease in the SGRQ-1 (p = 0.001). Palliative care intervention improves symptom and QoL in fILD.

Extracorporeal membrane oxygenation, although lifesaving, is invasive. Complications affecting all body systems mandate reevaluation of goals of care. When extracorporeal membrane oxygenation is nonbeneficial, planning for de-escalation/decannulation to allow natural death must occur. In a tertiary care facility with 64 beds using extracorporeal membrane oxygenation, practices varied regarding extracorporeal membrane oxygenation initiation, patient/family communication, futility determination, and symptom management during de-escalation. Symptom management during transition to comfort-directed care was suboptimal, increasing patient, family, and team discomfort. The goals of this quality improvement project were to mitigate practice variability and improve patient experience and communication, allowing for comfortable, natural death. Palliative care integration, literature review of best practices, and creation of an interprofessional task force were process improvements during extracorporeal membrane oxygenation de-escalation. New clinical guidelines provided structure, consistency, and evidence-based care processes mitigating practice variability during de-escalation/decannulation. Successful guideline implementation decreased practice variability, lessening patient/family stress and discomfort. After implementation, team member self-reports of secondary trauma and moral distress symptoms during extracorporeal membrane oxygenation de-escalation/decannulation decreased. Team members reported improved end-of-life care delivery with family education and support, patient advocacy, and symptom management. Family members appreciated attention to the patient's and their own well-being during end-of-life care. Structured debriefings helped staff members process feelings toward end-of-life care and identified opportunities for improvement. Guideline application decreased practice variability in extracorporeal membrane oxygenation de-escalation/decannulation, incorporating patient and family preferences. Death became more comfortable and dignified. Decreased practice variability and proactive symptom management improved patient/family experience.

To raise awareness of fertility preservation and counseling in palliative care and explore considerations for practice. This case report describes the rapid decline and death of a 36-year-old man with astrocytoma. Despite early fertility discussions with the palliative care team, sudden clinical deterioration prevented semen collection prior to death. Following death, the spouse requested post-death sperm retrieval. Post-death sperm retrieval and cryopreservation were successfully completed within the viability window. To achieve this, urgent interdisciplinary coordination across palliative care, emergency medicine, reproductive specialists, and hospital legal and executive teams was required. The case highlights the importance of early and ongoing fertility counseling for patients of reproductive age in palliative care. It demonstrates that clear pathways and coordinated systems can enable post-death sperm retrieval when aligned with patient and partner wishes. The development of evidence-based policies, training, and patient resources may reduce barriers and support clinicians to conduct sensitive, informed fertility discussions.

&#x2009;The study evaluated several approaches for identifying IN and OUT of bedtimes, comparing their reliability, accuracy, and impact on calculating sleep and circadian parameters. In a 12-month observational study, 72 adults with advanced cancer wore wrist and thigh accelerometers for 72 hours and completed sleep diaries and questionnaires on chronotype, sleep quality, and daytime sleepiness. IN and OUT times were determined using patient diaries, wrist accelerometry event markers, and automated accelerometry algorithms. Automated algorithms identified IN and OUT times more consistently than patient-reported methods (93-100% vs. 48-83%), although both under- and over-estimation of timings occurred. Timings from all methods were significantly correlated (p&#x2009;<&#x2009;0.001). Excellent agreement was observed between patient&#x2011;reports (patient diary and watch event marker, ICC 0.829-0.877), and patient-reports and thigh accelerometry (ICC 0.892). Event markers appeared more accurate than sleep diaries, showing closer agreement with associated DOWN and UP times. The choice of method for identifying IN and OUT times influenced the calculated sleep onset latency, percent sleep and dichotomy index values. These findings highlight the importance of accurate bedtime identification for reliable sleep and circadian analyses, particularly when diagnosed thresholds are used. Further research is required to determine the most accurate and clinically practical approach.

The abscopal effects (AEs), characterized by tumor regression beyond the site of local treatment, represents a promising therapeutic approach for metastatic cancer. Initially employed as a palliative measure for advanced disease, local antitumor therapy has been shown to elicit AEs through the activation of antitumor immunity. This review provides an in-depth exploration of reports on the induction of AEs, their mechanisms, predicators and enhancement strategies. Various local treatment modalities can induce immunogenic cell death in tumor cells, thereby triggering immune-mediated distant antitumor effects. Although abscopal effects is rarely induced by local treatment alone, several approaches have been developed to potentiate it. This review summarizes these enhancement strategies, discusses existing knowledge gaps, and highlights the substantial clinical potential of abscopal effects.

Malignant tumours account for approximately 20%-30% of primary cardiac tumours, and reports remain rare. Cardiac angiosarcoma is a representative type, but prognosis is extremely poor: the median survival is about 4 months in unresectable cases and 14 months after complete resection [Patel SD, Peterson A, Bartczak A, Lee S, Chojnowski S, Gajewski P, et al. Med Sci Monit 2014;20:103-9].Approximately 29% of angiosarcomas present with metastasis at diagnosis, and the presence of pericardial effusion suggests pericardial invasion. Evidence regarding chemotherapy remains limited, and no standardized treatment has been established for metastatic primary cardiac tumours. We report a case of cardiac angiosarcoma in a 74-year-old man. At the time of presentation, masses were detected in the right atrium and the apex of the left ventricle. The right atrial tumour extended widely along the atrial wall and partially formed fistulous tracts, resulting in direct communication of blood flow from the right atrium into the pericardial cavity. Surgical tumour resection with atrial wall reconstruction was performed, and chemotherapy was initiated following histopathological confirmation. Due to their poor prognosis, cardiac tumours are often managed with palliative care. This case highlights two important points: first, cardiac angiosarcoma can cause atrial wall destruction and rupture, leading to direct communication between the atrium and pericardial space; second, even in cases of primary cardiac angiosarcoma with pulmonary metastases, appropriate cardiac surgery combined with chemotherapy may improve patient outcomes.

In this planned analysis of a study on the effects of dorsal root ganglion stimulation (DRGS) on sleep and functional outcomes, we evaluated device-related complications, with a focus on lead fracture. Data were extracted for adult patients treated with DRGS between January 2018 and February 2025 from a clinical registry; patients with &#x2265;1 follow-up were included. Device-related adverse events, including lead fracture and migration, were identified and cross-checked against clinic notes, operative reports, and device interrogation data. Cumulative fracture probability was determined with Kaplan-Meier estimation; multivariable Cox regression was used to identify predictors of fracture. A standardized fascial anchoring technique was implemented in mid-2020 and its influence on events was assessed. A total of 92 patients received 375 leads with a median follow up of 1059 days (interquartile range [IQR]: 529, 1661.5 days). Lead fracture occurred in 37 of 375 leads (9.9%), affecting 21 of 92 patients (22.8%) with an incidence of 3.2% per lead per year. Six patients had multiple fractured leads. Cumulative incidence increased gradually with follow-up, reaching an estimated 15% at 60 months. In multivariable Cox analysis, body mass index (BMI) was the only independent predictor of fracture (HR: 0.943 per kg/m2; 95% CI, 0.893-0.996; p = 0.037); age, sex, lead level, laterality, number of leads, and primary diagnosis were not significant predictors. Crude incidence of fracture was 11.9% in unanchored leads versus 8.6% in anchored leads; however, time-to-event curves were similar, and anchoring was not an independent predictor. Most patients with fractured leads underwent revision (17/21); four experienced a second fracture. Lead migration occurred in four of 375 leads (1.2%) among four patients, mostly before routine anchoring was implemented at our center in June 2020. Five patients (5.4%) underwent explantation. Lead fracture remains a hinderance to long-term durability of DRGS therapy although events were usually manageable with restoration of therapeutic effect. Anchoring did not change fracture risk but coincided with low migration rates. BMI was the only significant predictor of fracture.

The International Paediatric Oncology Society Global Mapping Programme aims to collect data on global paediatric oncology services by continent, with Africa and Latin America completed. This study reports on the methodology and lessons learned for Oceania, a unique continent with resource disparity across countries, multiple small island developing states, small populations and complex climate and cultural factors. Recruitment and data collection processes have built invaluable regional connections and highlighted the challenges impacting regional childhood cancer care. This first comprehensive overview of paediatric oncology capacity in Oceania addresses a critical evidence gap and will inform future cancer control plans and advocacy.

Facial pain in patients with metastatic cancer is often multifactorial, involving neuropathic, nociceptive, and treatment-related mechanisms. Conventional therapies such as opioids, neuropathic agents, and corticosteroids are frequently inadequate or poorly tolerated. The sphenopalatine ganglion block (SPGB) is a minimally invasive procedure that may offer effective pain relief; however, data on the use of this technique for cancer-related facial and somatic pain is limited. We describe a 73-year-old woman with widely metastatic breast cancer who presented with severe, continuous facial pain involving her jaw, lips, cheeks, and ears, along with deep lower back pain, burning tongue pain, and bilateral thigh pain. Previous pharmacological treatments provided insufficient relief. She underwent multiple intranasal SPGB procedures with 0.5% bupivacaine administered via cotton-tip applicators. Following each treatment, she experienced nearly complete resolution of facial and somatic pain. That relief lasted from 3 days up to one week, even during concurrent chemotherapy and radiation therapy. The patient tolerated the procedures well, without adverse effects, and reported substantial improvement in her quality of life. This case highlights the intranasal bupivacaine SPGB as a simple, safe, and effective noninvasive option for refractory cancer-related facial and somatic pain. The observed relief beyond craniofacial areas suggests potential central modulation of pain pathways. Further research is warranted to validate the SPGB as a palliative treatment in advanced cancer pain syndromes.

BACKGROUND Thoracic SWI/SNF-related matrix-associated actin-dependent regulator of chromatin subfamily A member 4 (SMARCA4)-deficient undifferentiated tumor (SMARCA4-UT) is a rare and highly aggressive thoracic malignancy. It predominantly affects male smokers and typically arises in the mediastinum, where rapid tumor growth and early metastasis contribute to a poor prognosis. Recent evidence suggests that this tumor exhibits biological heterogeneity and variable responses to therapy, underscoring the need for further clinical characterization. CASE REPORT A 67-year-old man presented with dyspnea and superior vena cava syndrome. Computed tomography revealed a 7-cm mass in the anterior and superior mediastinum with suspected lymph node and bone metastases. Histological examination demonstrated a sheet-like proliferation of large atypical cells with rhabdoid features and necrosis. Immunohistochemical analysis showed loss of SMARCA4 (Brahma-related gene 1 [BRG1]) expression, positivity for cluster of differentiation 34 (CD34) and sex-determining region Y-box 2 (SOX2), weak epithelial membrane antigen expression, preserved integrase interactor 1 (INI1) expression, and negativity for other epithelial markers, fulfilling the diagnostic criteria for SMARCA4-UT. Despite palliative radiotherapy and combination immunotherapy with nivolumab and ipilimumab, the tumor rapidly progressed. The patient developed grade 4 drug-induced pneumonitis; transient stabilization was achieved, but his condition deteriorated. He died 6 months after disease onset. Autopsy revealed widespread metastases with minimal therapeutic effect, highlighting the aggressive clinical course and treatment resistance. CONCLUSIONS SMARCA4-UT is a highly aggressive tumor requiring comprehensive immunohistochemical evaluation for accurate diagnosis. This case highlights the limited efficacy of immune checkpoint inhibitors in a PD-L1-negative setting and underscores the need for more effective therapeutic strategies.

Accelerated silicosis is an aggressive form of pneumoconiosis increasingly observed among young artisanal gold miners. In high tuberculosis (TB) burden settings, its diffuse miliary radiological pattern frequently leads to misdiagnosis as miliary TB, resulting in inappropriate management and delayed supportive care. We present the case of a 24-year-old male artisanal gold miner in Uganda who presented with a five-month history of progressive dyspnea, cachexia, and fevers. A chest radiograph showed a diffuse miliary pattern, leading to a presumptive diagnosis of smear-negative pulmonary tuberculosis. Despite completing a standard six-month course of anti-tubercular therapy, his condition deteriorated with worsening hypoxia. Subsequent High-Resolution Computed Tomography (HRCT) revealed extensive bilateral upper-lobe Progressive Massive Fibrosis (PMF) with calcifications, a persistent thick-walled cavity, and pulmonary artery enlargement indicative of cor pulmonale. The diagnosis was revised to advanced accelerated silicosis complicated by pulmonary hypertension. This case highlights the critical diagnostic "mimicry" between silicosis and TB. In occupationally exposed individuals, a lack of microbiological confirmation and non-response to empirical TB treatment should trigger immediate radiological re-evaluation using HRCT to avoid unnecessary drug toxicity and ensure appropriate palliative intervention.

A man in his 70s presented with right ocular pain, visual disturbance, forehead swelling and left iliac pain. Diagnostic imaging revealed a large right orbital-frontal mass with skull involvement, a cavitary lesion in the right upper lobe and a left iliac lesion. Histological and molecular analyses confirmed lung adenocarcinoma with a MET exon 14 skipping mutation. Initial management focused on symptom control via palliative radiotherapy to the orbital and iliac lesions which achieved rapid relief. Following molecular confirmation, tepotinib-a selective MET tyrosine kinase inhibitor-was initiated. This resulted in clinical stability and a slight radiographic reduction of the primary lung lesion. This case highlights an atypical clinical manifestation of orbital metastasis in MET-mutated non-small-cell lung cancer. It underscores the clinical necessity of prompt tissue diagnosis and molecular profiling in patients presenting with atypical metastatic sites to facilitate the timely initiation of targeted systemic therapies.

Medullary thyroid carcinoma (MTC) may rarely cause malignant central airway obstruction (MCAO) through locoregional tracheal invasion, requiring urgent multidisciplinary management. In unresectable thyroid cancer-related MCAO, interventional bronchoscopy with airway stenting can provide rapid restoration of airway patency and symptomatic palliation. A 58-year-old nonsmoking woman with a history of MTC treated with total thyroidectomy and adjuvant radiotherapy presented with progressive exertional dyspnea, productive cough, intermittent mild stridor, and recurrent respiratory infections. She was tachycardic and tachypneic but maintained oxygen saturation on room air. Physical examination revealed a firm, fixed mass in the thyroid bed region. Laboratory investigations showed mild anemia and thrombocytosis. Computed tomography demonstrated approximately 5 cm of tracheal involvement with critical luminal narrowing, consistent with malignant tracheal stenosis from suspected locoregional recurrence. Tracheal biopsy revealed high-grade carcinoma considered clinically compatible with recurrence, although immunohistochemistry and RET mutation testing were unavailable. The disease was deemed unresectable due to local invasion involving the trachea and carotid sheath. Because systemic targeted therapy was not locally available, urgent airway palliation was prioritized. A covered self-expanding metallic tracheobronchial stent was placed successfully across the stenotic segment, resulting in meaningful improvement in breathing and phonation. Covered metallic airway stenting is an effective palliative option for long-segment unresectable malignant tracheal stenosis caused by recurrent MTC, particularly when systemic targeted therapy is unavailable and rapid airway stabilization is required.