Palliative Care Center Research Articles

Ultrasonographically Measured Rectus Femoris Cross-sectional Area might Predict Osteosarcopenia.

We have aimed to investigate the role of ultrasonographic muscle parameters (UMP) in predicting osteosarcopenia in bedridden patients in a palliative care center. The role of ultrasound has not been evaluated in predicting osteosarcopenia. Reduced muscle thickness (MT) and cross-sectional area (CSA) have often been observed in individuals with sarcopenia, reflecting muscle loss and atrophy. Meanwhile, the potential role of muscle ultrasound has not been evaluated in predicting osteosarcopenia. We have conducted a prospective, observational study between January 2021 and 2022. We have recorded the demographics, comorbidities, and nutritional status by using the mini nutritional assessment-short form. We measured handgrip strength with a hand dynamometer and the muscle mass with dual X-ray absorptiometry. Sarcopenia was defined by the European Working Group on Sarcopenia in Older People 2 criteria. Osteoporosis was diagnosed according to the World Health Organization criteria. We have categorized the body phenotypes into four groups: "non-sarcopenic non-osteoporotic," "sarcopenic alone," "osteoporotic alone," and "sarcopenic osteoporotic." We have measured the subcutaneous fat thickness (SFT), MT, and CSA of the rectus femoris (RF) and biceps brachii (BB) via ultrasonography. A multivariate regression analysis was performed and area under curve (AUC) values were used to evaluate the accuracy of UMPs. We included 31 patients (mean age: 74.6±12.1 years, 54.8%: male). The prevalences of sarcopenia, osteoporosis, and sarcopenic osteoporosis were 71%, 48.4%, and 41.9%, respectively. Only the "sarcopenic osteoporotic" phenotype was negatively correlated with all UMPs. In the regression analysis, only the "sarcopenic osteoporotic" phenotype was independently associated with RFCSA (ß=-0.456, p= 0.024). The AUC for all patients was >0.700. RFCSA measurement might be useful in the screening for osteosarcopenia. This has been the first study investigating the relationship between UMPs and body phenotypes. Multi-center and large-scale studies are, however, needed.

Assessing the need for home-based end-of-life palliative care in pediatric cancer care

Background: Palliative care is underrepresented in our community at large. End-of-life care is offered mainly in palliative care hospices or hospitals worldwide. As access to such a facility is often sparse, and since many of them are located far away from home, most families wish to go home if a curative treatment option does not exist. Aims and Objectives: The study was done to analyze the preferences for the location of end-of-life care for families of children with cancer. We analyze the reasons for the same and offer suggestions for improving this situation. Materials and Methods: Parents of 77 children who died following a diagnosis of childhood cancer between 2019 and 2023, either due to progressive or refractory disease or due to toxic death, were interviewed to understand their choice of location for end-of-life care. The interview was done telephonically or face to face. Results: 41 out of 77 deaths were anticipated, and out of these, we observed that only 3 (7.3%) opted for a formal palliative care center. Fifteen families (36%) opted for end-of-life treatment in the hospital, and 23 families (56%) went home despite having no support at home for palliation. The decision is taken considering the practical needs of the rest of the family, although it is more difficult to implement. The reasons behind the decision are analyzed here. Conclusion: We recommend that integrated home-based palliation for end-of-life care in children be developed instead of hospice support. Hospices that take care of adults may be used with children where required. A multidisciplinary team that can support the needs of families and can visit them at home needs to be developed around centers managing children with cancer.

The Effect of Back Massage Applied to Palliative Care Patients on Sleep Quality and Pain

In this article, I would like to share my comments about the article titled 'The Effect of Back Massage Applied to Palliative Care Patients on Sleep Quality and Pain' (1). In the current article, Durmaz et al. determined that there was a statistically significant increase in the patients' sleep quality and a significant decrease in their pain levels, starting from the 4th day of applying back massage to palliative care patients for 7 days (1). Pain may occur in patients in palliative care centers due to various reasons. In this article, I will try to contribute to the article from the perspective of a physical medicine and rehabilitation physician.

Adverse drug reactions seen in cancer patients undergoing palliative care treatment at a palliative care center in Alappuzha

Background: Adverse drug reactions are a major contributor to morbidity and hospitalization in patients and have been held responsible for as much as 5% of hospital admissions. This is especially relevant in cancer patients undergoing palliative care because they often suffer from advanced/terminal cancer and the adverse drug reactions from the palliative care drugs can affect their remaining quality of life. Aim and Objectives: The aim of this study was to study the adverse drug reaction profile of palliative drugs used in cancer patients undergoing palliative care at the Pain and Palliative Care OPD and their association with gender, age, dose, and duration of opioid intake. Materials and Methods: After receiving permission from the Institutional Ethics Committee, TDMC Alappuzha, 138 eligible cancer patients receiving palliative care from the pain and palliative care OPD were included in the study. The necessary data were obtained through interviews with the patients, who had given their consent to the study and the information was used to fill a questionnaire. Results: Out of the 138 study participants, 96 were male and 42 were female. The age composition ranged from 35 years to 88 years of age. There were 30 diabetic patients, 28 hypertensive patients, and 13 patients with CAD. The most frequent adverse effects, seen within 2 weeks of a 5 mg dose oral morphine regimen, were nausea (58.26%), constipation (51.18%), vomiting (43.30%), insomnia (33.07%), sedation (31.49%), dry mouth (25.19%), abdominal discomfort (24.04%), edema (20.47%) and tremors (19.68%). Using the modified Naranjo algorithm, 12% of ADRs were doubtful, 40% of ADRs were possible, 32% of ADRs were probable, and 16% of ADRs were definite. Among male patients taking 5 mg oral morphine, the most frequent ADRs were nausea (56.25%), constipation (45.31%), vomiting (40.62%), insomnia (34.37%), sedation (26.56%), dry mouth (21.87%), abdominal discomfort (18.75%), and edema (17.18%). Among female patients, the most frequent ADRs were vomiting (58.62%), nausea (55.17%), constipation (55.17%), abdominal discomfort (34.48%), dry mouth (31.03%), insomnia (31.03%), tremors (31.03%), sedation (24.13%), edema (20.68%), and pruritus (20.68%). Almost no significant associations were seen w.r.t to age, dose, and duration of opioid intake. Conclusion: The study identified the adverse effects associated with palliative care and their relative incidence. It also attempted to derive a correlation between the incidence of adverse effects and the age and gender of patient, the dose, and duration of opioid use.

EVALUATION OF A PATIENT WITH LUNG CANCER IN A PALLIATIVE CARE CENTER IN ACCORDANCE WITH THE ROPER, LOGAN, TIERNEY NURSING MODEL: A CASE REPORT

Lung cancer creates a significant burden on the health care system in the world, with its high incidence, the need for advanced technology in diagnosis and treatment, and the need for additional health services. Supporting the patient's care and independence and finding solutions to existing problems in the rapidly increasing number of terminal stage patients with lung cancer in the world and in our country require a very comprehensive approach. Care, one of the most important functions of nursing, is a concept that should not be ignored in nursing practices in the rapidly changing and developing field of health. The care plan should be designed with an individualized nursing care philosophy, taking into account individual differences, the course of the disease, and differences between patient types. In this direction, the Nursing Model Based on Daily Living Activities systematizes and groups care for individuals with a holistic approach and allows the individual to diagnose how much he can do these activities on his own and independently. In this way, the individual can be allowed to go through the pre-death process in a manner worthy of human dignity. Aim: In this case report, it is aimed to diagnose, evaluate and manage the nursing process of a lung cancer patient hospitalized in a palliative care center in accordance with the "Roper, Logan, Tierney Nursing Model". Method: A 67-year-old male patient, hospitalized in a city hospital palliative care center in Turkey, is receiving treatment and rehabilitation with the diagnosis of "Pulmonary Disease". During the rehabilitation process, the patient was handled with a holistic approach and diagnosed with the contribution of the nursing model based on daily life activities, the nursing process was managed, the nursing diagnoses identified in the patient and interventions appropriate to these diagnoses were planned and implemented. The case report study was explained and verbal and written informed consent was obtained from the patient's relative. Results: After the analysis of the systematized data, the problems were revealed more clearly and solution-oriented approaches were developed. Conclusion: It has been observed that the application of the nursing model based on daily life activities in the nursing process increases the quality of care.

Evaluation of Perspectives Among Elderly Patients and Their Relatives in Palliative Care Centers in Istanbul

In Turkey, there are not many studies on palliative care and its centers especially for the elderly. In this study, the perspectives of elderly patients and their relatives on palliative care centers were evaluated. It is thought that this study will be a guide for palliative care centers especially for the elderly and will be beneficial in terms of the effectiveness of palliative care practices. Questionnaire method was used in the research. The scale consists of questions measuring demographic information and the evaluation of the perspectives of elderly patients and their relatives on palliative care centers, including the care and treatment of the patient, informing the patient's relatives, perception, interest in the patient's relatives, the effect on the emotionality of the patient's relative, the waiting environment of the palliative care unit, and the decision-making process. A palliative care satisfaction scale consisting of 7 sub-dimensions was used. The population of the research consists of elderly patients receiving palliative care in Istanbul and their relatives. The sample consists of service recipients from the public and private sectors. The research was carried out in 2020-2021. A total of 333 people was reached, including elderly patients and their relatives in Istanbul. According to the findings obtained as a result of the analysis; palliative care satisfaction is positive and 78.75%. The highest mean value of 3.52 (88%) belongs to the dimension of concern for the caring for the patient's relatives Then, respectively, 3.30 (82.5%) care and treatment of patients, 3.26 (81.5%) perception, 3.19 (79.75%) giving information to the patient’s relatives 3.00 (75%) affect to emotion situation of patient’s relatives 2.95 (73.75%) and the decision-making process was 2.94 (73.5%) and Palliative care waiting environment. The highest average caring for the patient's relatives and lowest average palliative care waiting environment. It is seen that to increase the perspective towards palliative care centers in a positive way, improvements should be made in the waiting environments of palliative care centers and patients and their relatives should be included more in the decision-making processes.

Reflections of nursing students on the care of the person's dignity at the end of life: A qualitative study

BackgroundThe education of nursing students not only implies transmitting knowledge and clinical skills, but also values, attitudes, and behaviours. In healthcare, it is considered essential to respect and preserve the dignity of people. This is even more important in palliative care, where the fragility of people makes them potentially vulnerable. There is limited knowledge regarding the conceptualization and experience of nursing students and human dignity in palliative care. AimTo describe how 5th-year nursing students conceptualise and experience human dignity, while caring for people with terminal illness. DesignQualitative descriptive design, with thematic content analysis as per Graneheim and Lundman. SettingA palliative care centre for people on low incomes with terminal illnesses which no longer respond to curative treatments. ParticipantsA total of 11 fifth-year nursing students who completed their professional practice in a palliative care unit. MethodsData collection was conducted through guided online reflections via reflective journaling between April and November 2020. The study protocol was reviewed and approved by the Scientific Ethical Committee within the educational institution (CEC2021065). ResultsFour thematic categories were identified (1) Concept of dignity; (2) Dignity: an essential element in the relationship with others, (3) Instances when the dignity of the person is not considered; (4) The value of reflection on dignity in clinical practice. ConclusionDignity is one of the main values recognized in the person. Dignity should be promoted in the education of future nursing professionals, particularly with people who are in the final stage of life, where fragility and vulnerability it is more palpable.

Dexmedetomidine at Home for Intractable Dystonia and Insomnia in Children With Special Needs: A Case Series.

We know that syndromic conditions and severe chronic diseases can be associated with symptoms that may interfere with sleep, significantly impacting the life quality of children and caregivers. Drugs commonly used in treating insomnia, such as melatonin, benzodiazepines, niaprazine, and antihistamines, are often either ineffective or associated with adverse effects, requiring new therapeutic perspectives. Dexmedetomidine is a selective alpha-2 agonist with hypnotic and anxiolytic effects, which, by stimulating alpha-2 adrenergic receptors in the locus coeruleus, induces sleep comparable to stages 2-3 of the non-REM phase without substantially affecting the respiratory drive during sedation. Its use has already been extensively described in pediatric intensive care or procedural sedation literature. In 2018, the Italian Medicines Agency (Agenzia Italiana Del Farmaco AIFA) authorized the off-label use of dexmedetomidine outside of intensive care in Children undergoing palliative treatment to control distressing symptoms related to pathology and refractory sleep disorders, and the literature reported cases of children who received dexmedetomidine at home. Our study aims to describe the home use of dexmedetomidine in children with insomnia or intractable dystonic states. We conducted a retrospective analysis through a questionnaire addressed to 12 Italian pediatric palliative care centers regarding the home use of dexmedetomidine in sleep disorders and intractable dystonic states. We collected a case series of 9 children treated with dexmedetomidine at home, 8 via intranasal and 1 via intravenous route. All children received the first drug administration in the hospital or hospice during a dedicated admission, under close monitoring of vital signs parameters for 72 hours (3 days, range 2-7 days). After discharge, the potential side effects of the drug were explained to the patient's families, and, once informed consent was obtained, the home administration of dexmedetomidine continued, with follow-up by the palliative care team. At home, dexmedetomidine was administered for 3000 days (minimum 1 month, maximum 36 months). The first patient was treated for 1095 days, from 2019 to 2021 (discontinued due to underlying condition-related death). All patients observed a persistent benefit from the treatment on symptoms, and none of them discontinued dexmedetomidine administration due to drug-related adverse effects or perceived lack of therapeutic efficacy. Therefore, its use at home may represent a promising therapeutic approach for intractable sleep disorders or dystonic states in pediatric palliative care children. Further studies are needed to confirm our results.

What do parents think about the quality and safety of care provided by hospitals to children and young people with an intellectual disability? A qualitative study using thematic analysis.

Children with intellectual disability experience patient safety issues resulting in poor care experiences and health outcomes. This study sought to identify patient safety issues that pertain to children aged 0-16 years with intellectual disability admitted to two tertiary state-wide children's hospitals and a children's palliative care centre; to describe and understand these factors to modify the Australian Patient Safety Education Framework to meet the particular needs for children and young people with intellectual disability. Parents of children with intellectual disability from two paediatric hospitals and a palliative care unit participated in semi-structured interviews to elicit their experiences of their child's care in the context of patient safety. Thirteen interviews were conducted with parents from various backgrounds with children with intellectual, developmental and medical diagnoses. Eight themes about safety in hospital care for children and young people with intellectual disability emerged from thematic analyses: Safety is not only being safe but feeling safe; Negative dismissive attitudes compromise safety, quality and care experience; Parental roles as safety advocates involve being heard, included and empowered; Need for purposeful and planned communication and care coordination to build trust and improve care; Systems, processes and environments require adjustments to prevent patient safety events; Inequity in care due to lack of resources and skills, Need for training in disability-specific safety and quality issues and Core staff attributes: Kindness, Patience, Flexibility and Responsiveness. Parents highlighted the dilemma of being dismissed when raising concerns with staff and being required to provide care with little support. Parents also reported a lack of comprehensive care coordination services. They noted limitations within the healthcare system in accommodating reasonable adjustments for a family and child-centred context. The development of an adapted Patient Safety Education Framework for children with intellectual disability should consider ways for staff to transform attitudes and reduce bias which leads to adaptations for safer and better care. In addition, issues that apply to quality and safety for these children can be generalised to all children in the hospital. Parent advocates in the project advisory team were shown the questions to determine their appropriateness for the interviews.

COVID-19 in pediatric palliative care patients: Multicenter, retrospective cohort study

Background: Studies have shown the risk factors for COVID-19 severity in children, including comorbidities, but information on the infection course in children with life-limiting conditions is sparse. Aim: To describe the effect of COVID-19 on pediatric patients receiving palliative care due to life-limiting conditions. Design: We conducted retrospective cohort study. The WHO Clinical Progression Scale was used to measure COVID-19 severity. Setting/participants: Seven of the 24 invited pediatric palliative care centers participated in this study. We analyzed the medical records of children under palliative care with confirmed COVID-19 (January 2020–April 2022) Results: Records of 60 patients with COVID-19 aged 0.24 to 21.6 years (mean (SD); 9.8 (6.6)) were collected. The largest group of patients with COVID-19 was children with congenital malformations and chromosomal abnormalities (42%); the most common manifestation was fever (85%). Bacterial coinfection was confirmed in 17 (28%) children. Fifteen (25%) children required hospitalization, including four admitted to the Intensive Care Unit. Mild COVID-19 was identified in 44 (73%) children, moderate in 11 (18%), severe in 3 (5%), and death in 2 (3%). Six of the 20 eligible children were vaccinated against SARS-CoV-2, followed by 16 mothers and fathers. Conclusion: In the study population initial presentation of COVID-19 was predominantly a mild; however, the small sample size precluded definitive conclusions. For children under palliative care, we should identify if they have an advance care plan for COVID-19, such as desires for intensive care support. Further studies are needed to define the short and long-term effects of COVID-19 in children with life-limiting conditions.

Initiation of Palliative Care Referral from the Intensive Care Unit for Advanced Stage Metastatic Cancer Patients: A Quality Improvement Process from a Tertiary Referral Cancer Institute from South India.

Critically ill cancer patients in the intensive care unit (ICU) did not have any palliative care (PC) intervention as there was no PC referral from the ICU. The project aimed to initiate PC referral for at least 50% of progressive palliative intent cancer patients in intensive care to enhance communication with patients and caregivers. We included PC physicians, oncologists, and psychologists in the team for this project. We used the A3 problem-solving method of quality improvement (QI) and also used the Plan Do Check Act process. The first baseline assessment over 6 months of ICU deaths of patients who could have benefited from PC referral was collected; this made us realise that PC could have been initiated for some patients. Process maps of patient admission into the ICU and the process of their discharge were constructed. Analysis of root causes that were barriers to referral was examined. We made a PC trigger tool after team consultations and consensus and started using it to initiate PC referrals. PC discharge protocol was also initiated. Educational discussions were held with residents and nurses to ensure the continued use of the trigger tool. PC referral from intensive care slowly went up from 0% to beyond 50% by November 2019 and reached over 70% by March 2020; patients getting discharged had details of PC centres near their homes. Structured QI process and introducing the PC trigger tool led to the outcome of 50% PC referral for critically ill patients in ICU.

Survey of NCI-designated cancer centers on the utilization of palliative care in patients with pancreatic cancer.

248 Background: Pancreatic cancer, known as one of the deadliest cancers, has a high demand for palliative care. However, there remains a considerable amount of uncertainty regarding the nature of palliative care treatment to this specific patient demographic across the United States. This study aims to assess the utilization of palliative care in pancreatic cancer patients and explore the variations in timing and emphasis of palliative care involvement. Methods: We conducted a survey assessing utilization of palliative care in pancreatic cancer patients. We targeted palliative care directors at all 65 National Cancer Institute (NCI) cancer centers. The physicians were invited to voluntarily participate in the study. Responses were collected by email between May 30, 2023, and June 22, 2023. 1) Does your palliative care and/or oncology team have a policy to get involved with every pancreatic cancer patient (yes or no)? 2) When palliative care is involved with pancreatic cancer patients, in what setting are you typically/primarily first asked to be involved (early in the patient’s treatment journey, focusing more to assist with symptom management, or later in the patient’s treatment journey, focusing more on end-of-life discussions such as explaining hospice)? Results: We received responses from palliative care leaders at 65 NCI-designated palliative care centers, and thus 100% of the targeted population sample. Out of these centers, 64 indicated that there was no established policy for palliative care involvement with every pancreatic cancer patient. Among the respondents, 38 centers started intervention early, primarily focusing on symptom management, while 15 centers started palliative care late in the treatment process, with a focus on end-of-life discussions. Additionally, 12 centers reported that they first intervene both early and late when treating pancreatic cancer. Conclusions: The utilization of palliative care services improves various outcome measures. Pancreatic cancer has one of the lowest survival rates and is associated with significant morbidity. Our findings suggest an increasing recognition among medical centers of the need for palliative care services for pancreatic cancer patients. However, there is variation in the timing and emphasis of palliative care involvement, suggesting a need for further exploration in this area. Notably, there is a growing trend to integrate palliative care at an early stage. Future research should explore barriers to accessing palliative care, distinguish between inpatient and outpatient services, and compare outcomes of early versus late palliative care intervention. By addressing these areas, healthcare providers can enhance the quality of care and improve outcomes for pancreatic cancer patients.

Biceps brachii muscle cross-sectional area measured by ultrasonography is independently associated with one-month mortality: A prospective observational study.

Studies examining mortality in palliative care units are limited. We aimed to investigate the mortality and associated factors including ultrasonographic muscle parameters in hospitalized palliative patients with a subgroup analysis of older patients. A prospective-observational study. We recorded the demographics, number of diseases, diagnoses, and the Charlson comorbidity index (CCI), palliative performance scale (PPS), and nutritional risk screening-2002 (NRS-2002) scores. We noted the nutritional parameters and mortality. We measured the subcutaneous fat thickness (SFT), muscle thickness (MT), and cross-sectional area (CSA) of the rectus femoris and biceps brachii using ultrasonography. We enrolled 100 patients (mean age: 73.2 ± 16.4 years, 53%: female). One-month mortality was 42%. The non-survivors had significantly higher malignancy, increased CCI and NRS-2002 scores, lower required energy intake, calorie sufficiency rate, and biceps brachii SFT, MT, and CSA than the survivors. The independent mortality predictors were malignancy and biceps brachii CSA while the PPS score and malignancy were significantly associated with mortality in the older subgroup. The malignancy and biceps brachii CSA might have prognostic value in predicting mortality in palliative patients. This was the first study investigating the mortality-associated factors including ultrasonographic muscle measurements of both the lower and upper limbs in a palliative care center.

A trial-based cost-effectiveness analysis of antibiotic prescription strategies for non-complicated respiratory tract infections in children

BackgroundAntibiotic prescription for respiratory tract infections (RTIs) in children attending primary care centres is almost double that predicted according to bacterial prevalence. Delayed antibiotic prescription (DAP) is designed to deploy a more rational use of antibiotics. While studies have evaluated DAP efficacy and safety for children with RTIs, little research has been conducted on the economic implications.MethodsOur trial compared cost-effectiveness for DAP, immediate antibiotic prescription (IAP), and no antibiotic prescription (NAP) for children aged 2–14 years with acute uncomplicated RTIs attended to in 39 primary care centres in Spain. The main outcome was the incremental cost-effectiveness ratio (ICER), measured in euros per gained quality-adjusted life days (QALDs). Net monetary benefit (NMB) was also calculated as a tool for decision making. The analysis was performed from a societal perspective for a time horizon of 30 days, and included healthcare direct costs, non-healthcare direct and indirect costs, and the antimicrobial resistance (AMR) cost.ResultsDAP was the most cost-effective strategy, even when the cost of AMR was included. QALD values for the three strategies were very similar. IAP compared to DAP was more costly (109.68 vs 100.90 euros) and similarly effective (27.88 vs 27.94 QALDs). DAP compared to NAP was more costly (100.90 vs 97.48 euros) and more effective (27.94 vs. 27.82 QALDs). The ICER for DAP compared to NAP was 28.84 euros per QALD. The deterministic sensitivity analysis indicated that non-healthcare indirect costs had the greatest impact on the ICER. The cost-effectiveness acceptability curve showed that DAP was the preferred option in approximately 81.75% of Monte Carlo iterations, assuming a willingness-to-pay value of 82.2 euros per gained QALD.ConclusionsWhen clinicians are in doubt about whether an antibiotic is needed for children with RTIs attending PC centres, those treated with the DAP strategy will have slightly better efficiency outcomes than those treated with IAP because its costs are lower than those of IAP. DAP is also the most cost-effective strategy over a time horizon of 30 days if AMR is considered, despite higher short-term costs than NAP. However, if in the long term the costs of AMR are larger than estimated, NAP could also be an alternative strategy.Trial registrationThis trial has been registered at www.clinicaltrials.gov (identifier NCT01800747; Date: 28/02/2013 (retrospectively registered).

The relationship between caregiver burden and anger level of informal caregivers of patients in palliative care centre.

Palliative care is a comprehensive service that includes not only the patient but also the caregivers. This research was carried out to determine the relationship and factors affecting the burden and anger level of informal caregivers of patients. This descriptive study was conducted with caregivers (n=206) of patients hospitalised in two Palliative Care Centers in Ordu, Türkiye. In the research, it was determined that there was a statistically significant relationship between the burden of caregivers and the trait anger level, anger-in, anger-out sub-dimension scores of The Trait Anger and Anger Expression Scale, but a negative relationship was found between the burden of caregivers and anger control sub-dimension scores of The Trait Anger and Anger Expression Scale. The burden of a caregiving process has a positive impact on the trait anger level, anger-in, anger-out but has a negative impact on anger control. Nurses should monitor a caregiver's level of anger and burden and develop programmes required to decrease the caregiver's anger level and burden.

Evaluation of Demographic, Clinical Characteristics and Laboratory Values of Pediatric Patients Followed in Palliative Care

Background/Aims: The importance of pediatric palliative care centers, which we think is insufficient both in the world and in our country, is increasing. The aim of this study is to reveal the demographic, clinical and laboratory characteristics of pediatric patients followed in a palliative care center.
 Methods: In this retrospective study, demographic data (age, gender), laboratory findings (platelet, mean platelet volume, lymphocyte, neutrophil counts, glucose, sodium, potassium, urea) of pediatric patients followed up in an adult palliative care center between 18.10.2018 and 15.01.2023, creatinine, albumin and the C-reactive protein, CRP/albumin ratio, platelet/lymphocyte ratio and neutrophil/lymphocyte ratio) and clinical features (length of stay in PCU and survival) were evaluated.
 Results: It was determined that 61 pediatric patients between the ages of 2-17 were followed up in the palliative care center between 18 October 2018 and 15 January 2023. 65.6% of the patients were male and 6.6% were Syrian citizens. The duration of stay in the palliative care center was between 1-64 days. While 16.4% of the patients had tracheostomy, 14.8% needed home mechanical ventilator. Only 3 (4.9%) patients received parenteral nutrition. The diagnosis of admission to the palliative care center of 47 (77.0%) patients included in the study had neurological sequelae after head trauma. The mortality rate was 1.6%.
 Conclusions: It is obvious that the centers are insufficient in the face of the increasing need for pediatric palliative care. Although adult palliative care centers are compensating for this deficiency at this stage, it is clearly seen that the number of pediatric palliative care centers should be increased in the future.

Validation of a French version of the Breakthrough Pain Assessment Tool in cancer patients: Factorial structure, reliability and responsiveness.

Breakthrough cancer pain should be properly assessed for better-personalized treatment plan. The Breakthrough Pain Assessment Tool is a 14-item tool validated in English developed for this purpose; no French version is currently available and validated. This study aimed to translate it in French and assess the psychometric properties of a French version of the Breakthrough Pain Assessment Tool (BAT-FR). First, translation and cross-cultural adaptation of the 14 items (9 ordinal and 5 nominal) of the original BAT tool in French language was made. Second, assessments of validity (convergent, divergent and discriminant validity), factorial structure (exploratory factor analysis) and test-retest reliability of the 9 ordinal items were done with data of 130 adult cancer patients suffering from breakthrough pain in a hospital-academic palliative care center. Test-retest reliability and responsiveness of total and dimension scores derived from these 9 items were also assessed. Acceptability of the 14 items was also assessed on the 130 patients. The 14 items had good content and face validity. Convergent and divergent validity, discriminant validity and test-retest reliability of the ordinal items were acceptable. Test-retest reliability and responsiveness of total and dimensions derived from ordinal items were also acceptable. The factorial structure of the ordinal items had two dimensions similar to the original version: "1-pain severity and impact" and "2-pain duration and medication". Items 2 and 8 had a low contribution to the dimension 1 they were assigned and item 14 clearly changed of dimension compared with the original tool. The acceptability of the 14 items was good. The BAT-FR has shown acceptable validity, reliability and responsiveness supporting its use for assessing breakthrough cancer pain in French-speaking populations. Its structure needs nevertheless further confirmation.

Impact of an outpatient palliative care consultation and symptom clusters in terminal patients at a tertiary care center in Pakistan

BackgroundPatients with terminal diseases may benefit physically and psychosocially from an outpatient palliative care visit. Palliative care services are limited in Pakistan. An improved understanding of the symptom clusters present in our population is needed. The first outpatient palliative care center in Karachi, Pakistan, was established at our tertiary care institution. The primary aim of this study was to evaluate the impact of a palliative care outpatient consultation on symptom burden in patients with a terminal diagnosis. The secondary aim was to analyze the symptom clusters present in our population.MethodsPatients with a terminal diagnosis referred to our outpatient palliative department between August 2020-August 2022 were enrolled. The Edmonton Symptom Assessment Scale (ESAS) questionnaire was administered at the initial visit and the first follow-up visit at one month. Change in symptom burden was assessed using a Wilcoxon signed ranks test. A principal component analysis with varimax rotation was performed on the symptoms reported at the initial visit to evaluate symptom clusters. The palliative performance scale (PPS) was used to measure the performance status of palliative care patients.ResultsAmong the 78 patients included in this study, the average age was 59 ± 16.6 years, 52.6% were males, 99% patients had an oncological diagnosis, and the median duration between two visits was 14 (Q1-Q3: (7.0, 21.0) days. The median PPS level was 60% (Q1-Q3: 50–70). Overall, ESAS scores decreased between the two visits (6.0 (2.8, 11.0), p < 0.001) with statistically significant improvement in pain (5.0 vs. 2.5, p < 0.001), loss of appetite (5.0 vs. 4.0, p = 0.004), depression (2.0 vs. 0.0, p < 0.001), and anxiety (1.5 vs. 0.0, p = 0.032). Based on symptoms at the initial visit, 3 clusters were present in our population. Cluster 1 included anxiety, depression, and wellbeing; cluster 2 included nausea, loss of appetite, tiredness, and shortness of breath; and cluster 3 included drowsiness.ConclusionAn outpatient palliative care visit significantly improved symptom burden in patients with a terminal diagnosis. Patients may benefit from further development of outpatient palliative care facilities to improve the quality of life in terminally ill patients.

Barriers and Facilitators of Palliative Care in Older Adults With Heart Failure: A Qualitative Content Analysis.

Objectives: The progressive and unpredictable course of heart failure (HF) has made the provision of palliative care (PC) services to older adults with HF a serious challenge. This study aimed to explain the barriers and facilitators of PC in older adults with HF. Methods: This qualitative study was conducted using the content analysis approach. A sample of 15 participants, including 6 patients, 2 family caregivers, and 7 healthcare team members (4 nurses, a psychiatric nurse, a nutritionist, and a PC physician) were selected by purposive sampling over 10 months (November 21, 2020 to September 1, 2021). The data were collected using semistructured in-person interviews until data saturation and analyzed with conventional qualitative content analysis. Results: The findings revealed the main category of "neglecting the provision of PC," with 4 subcategories of "weak organizational structure," "poor social support," "older adults' and healthcare teams' poor knowledge," and "limited financial resources" as the barriers of PC and the main category of "enjoying support potentials" with 3 subcategories of "the cooperation of the government, benefactors, and nongovernmental organizations," "empathy from the family and relatives," and "benefiting from the presence of healthcare workers" as PC facilitators. Conclusions: The findings of this study explained the barriers and facilitators of PC in older adults with HF. Removing the barriers and supporting the facilitators give older adults with HF better access to PC. Therefore, to expand PC centers for older adults with HF, health system officials, and policy-makers should pay attention to organizational infrastructures and remove the barriers at organizational, social, educational, and economic levels with the cooperation of governmental organizations, benefactors, and nongovernmental organizations.

Health professionals KAP study on rabies exposure assessment and NTV administration in Ethiopia

Background: Globally, it’s estimated 60,000 human deaths occur due to rabies with 95% of cases occurring in Africa and Asia. Annually, thousands of people are infected with rabies in Ethiopia and more than 2700 people die. In Ethiopia, the neural-based vaccine has been used since the 1950’s. Due to the old method of production, low immunogenicity and vaccine associated adverse events, WHO discourage the use of this vaccine and recommend replacing it with a safe and effective modern cell culture vaccine. There was no specific guidelines and training for this vaccine and health professional mismanage the nerve tissue vaccine (NTV) with cell culture vaccine resulting in vaccination failure. This study identifies professional knowledge, attitude and practice (KAP), vaccine related adverse events and the burden of rabies cases in humans. Methods: Data were collected from health professionals in selected health facilities using structured questionnaire to identify the level of KAP. Results: The study identified overall gaps in the professionals KAP as below standard which is not more than 25%. The majority of the respondents (97%) reported vaccine associated local adverse events followed by 20% systemic complications during vaccination. Only 2.4% of the respondents reported post-vaccine complications. Rabies cases in humans at those covered health facilities were reported to be 32 during the one-year study period with an average of two cases at each facility. Conclusions: Gaps identified in the professional KAP result indicate the need to provide specific training based on standard guidelines. Generally, the study indicates the need to strengthen rabies prevention and control efforts through inter-sectoral collaboration, and facilitating the establishment of facility-based rabies palliative care centers. In addition, it is recommended to work on technology transfer to replace old method of NTV production with safe and effective modern cell culture based anti-rabies vaccine production for effective rabies PEP.