Palliative Management Research Articles

Palliative care and good death in acute diseases: a scoping review protocol

Increasing cases of emerging and re-emerging infectious diseases, requires healthcare systems to provide essential palliative care for critically ill patients and their families. With the rapid onset and often accelerated deterioration in patients with acute conditions, palliative and supportive care for these patients have different characteristics compared to those for chronic diseases. Furthermore, providing end-of life services for critically ill patients with acute diseases and their families to ensure good death for the patients, will also have its own challenges. This scoping review aims to explore the concept of palliative care and good death for acute diseases. This scoping review will be conducted using the Arksey and O’Malley's framework for scoping reviews: identifying the research question, identifying relevant studies, study selection, charting the data, collating, summarizing, reporting results, and conducting consultation. All original research with a focus on palliative care and good death due to acute diseases will be included. This review will include all original research designs published between the period of 2000–2021 that describe a measure of palliative care management for and good death due to acute diseases. Quantitative, qualitative and mixed-method studies will be included in order to consider different aspects of healthcare services. This review will also include guidelines and gray literature on palliative care and good deaths. The search will be conducted through PubMed, Scopus Database, and ScienceDirect using the key terms related to acute disease palliative care and the concept of good death due to acute diseases. Two authors will screen the titles and abstracts of the studies. Two authors will review the full text of selected studies independently and extract the data. All selected studies will be synthesized qualitatively, and the results will be consulted with experts through discussion and depict the current concept of palliative care and good death in acute diseases.

Nurse prescribing in end-of-life care in the community: meeting patients' needs

This article outlines the important role of medicines in managing community-based palliative care in the last year of life, together with the central role of nurses prescribing in this context. The article discusses the key needs of patients and carers managing palliative care medicines in the home setting, which include a requirement for streamlined, rapid access to medicines, as well as information about and support for daily self-management of medicines. The article draws on recent research in the field of palliative care medicines management and highlights the implications for nurse prescribers.

The Relationships between Self-care and Coping Strategy among People Living with Human Immunodeficiency Virus

AIM: This study aims to examine the relationships between self-care and coping strategy among people living with human immunodeficiency virus (HIV) (PLWH). METHODS: A cross-sectional design involving 76 subjects of PLWH who attended the HIV clinic at a District Hospital in West Java Province, Indonesia. They met inclusion criteria such as being adult, has been living with HIV for over 1 year, and be able to communicate both verbal and written in Bahasa Indonesia. Self-care was measured by the 41-item Self-care Assessment Worksheet instrument, and coping strategies were measured by the 60-item Jalowiec Coping Scale. Pearson-product moment correlation was performed to examine the relationships between self-care and coping strategy scores. RESULTS: The majority of respondents (57.8%) used the emotion focused coping strategy such as supportant (31.5%) followed by fatalistic (21%) and optimistic (17.1%) when they deal with stressful situations. Optimistic coping was reported as the most effective coping by the respondents. Nearly half of respondents (42%) have intermediate self-care level which the highest number of self-care was medication. There was a significantly relationship between problem-focused coping strategy and the self-care scores (r = 0.378, p < 0.01). Confrontive coping strategy has positive correlation with symptoms management (r = 0.264, p < 0.05) and stress management (r = 0.280, p < 0.05). Self-care information has positive correlation with palliative coping strategy (r = 0.281, p < 0.05) and supportant coping strategy management (r = 0.236, p < 0.05). Prevention and medication have positive correlation with optimistic emotional coping strategy (r = 0.264, p < 0.05). CONCLUSION: Understanding PLWH coping strategies could assist nurses to reinforce patient’s positive coping strategies and change maladaptive coping strategies. Nurses could facilitate patients to develop a more adaptive coping strategies in enhancing self-care capability among PLWH.

A survey of cancer care institutions in Nepal to inform design of a pain management mobile application

BackgroundOne way to improve the delivery of oncology palliative care in low and middle-income countries (LMICs) is to leverage mobile technology to support healthcare providers in implementing pain management guidelines (PMG). However, PMG are often developed in higher-resourced settings and may not be appropriate for the resource and cultural context of LMICs.ObjectivesThis research represents a collaboration between the University of Virginia and the Nepalese Association of Palliative Care (NAPCare) to design a mobile health application (‘app’) to scale-up implementation of existing locally developed PMG.MethodsWe conducted a cross-sectional survey of clinicians within Nepal to inform design of the app. Questions focused on knowledge, beliefs, and confidence in managing cancer pain; barriers to cancer pain management; awareness and use of the NAPCare PMG; barriers to smart phone use and desired features of a mobile app.FindingsSurveys were completed by 97 palliative care and/or oncology healthcare providers from four diverse cancer care institutions in Nepal. 49.5% (n = 48) had training in palliative care/cancer pain management and the majority (63.9%, n = 62) reported high confidence levels (scores of 8 or higher/10) in managing cancer pain. Highest ranked barriers to cancer pain management included those at the country/cultural level, such as nursing and medical school curricula lacking adequate content about palliative care and pain management, and patients who live in rural areas experiencing difficulty accessing healthcare services (overall mean = 6.36/10). Most nurses and physicians use an Android Smart Phone (82%, n = 74), had heard of the NAPCare PMG (96%, n = 88), and reported frequent use of apps to provide clinical care (mean = 6.38/10, n = 92). Key barriers to smart phone use differed by discipline, with nurses reporting greater concerns related to cost of data access (70%, n = 45) and being prohibited from using a mobile phone at work (61%; n = 39).ConclusionsSmart phone apps can help implement PMG and support healthcare providers in managing cancer pain in Nepal and similar settings. However, such tools must be designed to be culturally and contextually congruent and address perceived barriers to pain management and app use.

Electrochemotherapy for the palliative management of non-skin-origin head and neck cancer: case series and UK national survey.

Electrochemotherapy uses electric fields to facilitate the influx of chemotherapy into cancer cells, producing a targeted effect. For head and neck cancer, it is mainly used for palliation of non-skin-origin metastases. It is used infrequently in the UK. This paper presents our experience and a UK survey to identify its frequency of use. Between 2016 and 2019, a prospective database was created and reviewed. Only patients with non-skin-origin metastatic head and neck cancer, with no other palliative options, were included. Survival length, complications and symptomatic benefit were assessed. The survey was conducted via e-mail. Five patients were included: three with squamous cell carcinoma, one with esthesioneuroblastoma and one with hepatocellular carcinoma. Survival ranged from 1 month to over 20 months. Minor complications were seen. Only 15 out of 69 UK head and neck multidisciplinary teams offer electrochemotherapy. Electrochemotherapy is a well-tolerated adjunct to standard palliation of metastatic head and neck cancer, and is offered by a limited number of UK multidisciplinary teams.

Stereotactic Body Radiotherapy (SBRT) for the Palliation of Unirradiated Mucosal Head and Neck Tumors

We report the treatment outcomes of palliative SBRT to primary mucosal unirradiated head and neck cancer (HNC) patients that were ineligible to receive conventional radiation therapy (RT) MATERIALS/METHODS: We retrospectively reviewed patients with primary mucosal HNC treated with SBRT from 2011-2020. Patients with histologies other than squamous cell carcinoma, with primary skin disease or with recurrent tumors were excluded. SBRT was used in this cohort of patients because of associated comorbidities that precluded full course RT. All patients were followed regularly with clinical examination and imaging. The endpoints were local failure (LF) defined as recurrence of tumor at the irradiated site, overall survival (OS), acute and late grade 3 and 4 toxicity.Sixty patients with a median age of 81 years were treated with SBRT technique. The median follow-up was 7.8 months. 8(13%), 38(63%), 13(22%) and 1(2%) were ECOG 1, 2, 3 and 4, performance status respectively. Oral cavity was the most common cancer site in our cohort (60%, 36 patients), followed by oropharyngeal cancer (15%, 9 patients), larynx (7%, 4 patients), hypopharynx (5%, 3 patients), parotid cancer (5%, 3 patients), unknown primary (5%, 3 patients) and nasal cavity/sinonasal cancer (3%, 2 patients). Tx-2 and T3-4 lesions were found in 18(30%) and 42(70%), respectively, while 32(53%) and 28(47%) were staged N0-1, N2-3, respectively. GTV was prescribed to 45 Gy in 5 fractions, most commonly used (55%), followed by 40 Gy in 5 fractions (37%). A high dose CTV was not used around GTV although an elective nodal volume of 25 Gy in 5 fractions was also used. 52 patients were treated twice a week completed in 13-20 days, 2 patients completed their treatments in 9 and 10 days, while 5 patients over 21-28 days. The cumulative incidence of LF at 6 and 12 months was 5.3% (95% CI 1.4-13.3) and 12.4% (95% CI 4.9-23.7), respectively. The median (OS) was 9.2 months. The 6 and 12 month OS rates were 67.9% (95% CI 56.6-81.4) and 41.4% (95% CI 29.2-58.7), respectively. Cancer was the cause of death in 12 patients (38%), while 20 deaths (62%) were not related to malignant disease. Acute G3 toxicity was observed in 23 patients, including G3 mucositis in 19 patients, G3 dermatitis in 2 patients and G3 dysphagia in 2 patients. Five patients developed G3+ late toxicity, including osteoradionecrosis (n = 3), soft tissue supraglottic ulceration (n = 1) and trismus (n = 1). Four of these 5 patients did not have evidence of concurrent local recurrence.HN SBRT has been largely reported in the re-irradiation setting, however, SBRT may have greater utility in the palliative management of previously untreated HNC patients. Despite the advanced age and performance status noted in this group of patients with mucosal SCC of the head and neck, who were not eligible for conventional RT, SBRT was associated with low local failure rates and reasonable toxicity profile. A randomized controlled trial is warranted to confirm the efficacy of HN SBRT in this setting.

A Comparative Clinical Study to Evaluate the Efficacy of Guduchyadi Kashaya and Rajrukshadipachana Kashaya in the Management of Eka Kushta w.s.r to Psoriasis

In Ayurveda, all skin diseases have been described under the umbrella of Kushtha. Ekakusta is considered as the most commonest skin disease that can affect an individual. Acharya Charak has described the involvement of Vata-Kapha in Eka Kushtha. In the present study Eka kushtha is compared with psoriasis due to resemblance of signs symptoms and causative factors with it. Psoriasis is a papulosquamous disorder of the skin, characterized by sharply defined erythematosquamous lesions this illness exhibits a prompt response if treated carefully, left it may run a very chronic course extending into larger area of the body.
 Ayurveda focuses more on curative management than palliative management. The drug used in the treatment of Ayurveda does not have complications like modern treatment. Repeated Sodhana prevent the recurrence of the disease. Similarly various preparations have been advocated for the management of Psoriasis.
 The drugs used in this study are Guduchyadi Kashaya & Rajrukshadi Pachana Kashaya. Both the Kashayas are said to be effective in skin diseases. As per Yogaratnakara, Guduchyadhi Kwath has been mentioned as one of the drug having curative effect on all types of Kustha. Hence for present study the orally Guduchyadi Kwath is taken for EkaKustha treatment. The drugs in Guduchyadi Kwatha are Kusthaghana, Twachya, Swedal, Tridosh shamaka, as well as with Rasayan properties, which is beneficial to break down the pathogenesis of disease. As per Gadanigraha, as mentioned in Kayachikitsakhanda, Rajvrukshadipachana Kashaya is mentioned for the treatment of Ekakushtha. Ingredients in Rajvrukshadi Pachana Kashaya reduce Kapha dosha and most of them act on the skin. Kwatha dravyas are Rasadushtihara, Kaphapittahara, Deepana, Twachya, and also having antibacterial, antimicrobial, antiparasitic and anti-inflammatory properties, Hence, it is helpful for clearing the skin infections.

Metastatic Penile Adenocarcinoma in the Context of Rectal Cancer

The presence of penile metastatic lesions proceeding from primary rectal tumors is a rare entity usually associated with a poor prognosis. Clinical presentation and localization may vary. There exists no consensus gold standard treatment for penile metastatic lesions, and there is continuous debate on whether lesions should undergo surgical, chemotherapeutic or palliative management.

Predicting potential palliative care beneficiaries for health plans: A generalized machine learning pipeline

Recognizing that palliative care improves the care quality and reduces the healthcare costs for individuals in their end of life, health plan providers strive to better enroll the appropriate target population for palliative care. Current research has not adequately addressed challenges related to proactively select potential palliative care beneficiaries from a population health perspective. This study presents a Generalized Machine Learning Pipeline (GMLP) to predict palliative needs in patients using administrative claims data. The GMLP has five steps: data cohort creation, feature engineering, predictive modeling, scoring beneficiaries, and model maintenance. It encapsulates principles of population health management, business domain knowledge, and machine learning (ML) process knowledge with an innovative data pull strategy. The GMLP was applied in a regional health plan using a data cohort of 17,197 patients. Multiple ML models were turned and evaluated against a custom performance metric based on the business requirement. The best model was an AdaBoost model with a precision of 71.43% and a recall of 67.98%. The post-implementation evaluation of the GMLP showed that it increased the recall of high mortality risk patients, improved their quality of life, and reduced the overall cost. The GMLP is a novel approach that can be applied agnostically to the data and specific ML algorithms. To the best of our knowledge, it is the first attempt to continuously score palliative care beneficiaries using administrative data. The GMLP and its use case example presented in the paper can serve as a methodological guide for different health plans and healthcare policymakers to apply ML in solving real-world clinical challenges, such as palliative care management and other similar risk-stratified care management workflows.

PORCELAIN PLEURA: A RARE CASE OF METASTATIC CHONDROSARCOMA WITH EXTENSIVE PLEURAL CALCIFICATION

TOPIC: Disorders of the Pleura TYPE: Fellow Case Reports INTRODUCTION: Calcified pleural lesions have both benign and malignant etiologies. Benign lesions can originate from previous trauma, prior pleural infections, hemothorax, or asbestos exposures, and are often focal and limited1,2. Malignant lesions often involve metastatic disease from mesenchymal tumor origin, such as osteosarcoma, chondrosarcoma, or mesothelioma1,3. We describe a case of a patient with metastatic chondrosarcoma manifesting with extensive calcification of the parietal and visceral pleura. CASE PRESENTATION: A 67 year old man was referred to pulmonary for a new subcarinal soft tissue mass on chest CT. He had been previously diagnosed with chondrosarcoma in 2016 and underwent treatment via a radical right proximal humerus excision and shoulder arthroplasty, with final pathology revealing grade 2 conventional chondrosarcoma, mixed hyaline and myxoid, without metastatic foci.Screening chest CT in 2020 noted a new, partially calcified subcarinal soft tissue mass and adjacent lymphadenopathy with moderate hypermetabolism on a positron emission tomography scan (PET/CT). Bronchoscopy with endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) subcarinal lymph node and adjacent posterior mass confirmed metastatic disease.He subsequently developed rapidly progressive dyspnea on exertion over the following month. Repeat chest CT revealed extensive development of circumferential nodularity and calcification of the right visceral and parietal pleura with a large pleural effusion. Thoracentesis improved dyspnea despite limited reexpansion of the lung and noted loculation of the effusion. Pleuroscopic evaluation of the complicated space was undertaken to remove loculations and optimize placement of an indwelling pleural catheter (IPC) for his malignant effusion. Despite difficulty with trocar insertion into the calcified pleural space, placement of the IPC was successful with improvement in his dyspnea. DISCUSSION: Metastatic pleural involvement of chondrosarcoma is rare, and can occur in the setting of direct extension in locoregional disease or hematogenous spread from other sites of primary involvement. Metastatic disease has been noted to be more prevalent in the dedifferentiated and mesenchymal subtypes4. Manifestations of metastatic pleural involvement are typically pleural calcifications that can be profound in the rapid evolution and extent of calcified involvement. Management is often palliative, as in this case, with drainage of any associated pleural effusions and attempts to mitigate accompanying dyspnea. CONCLUSIONS: This case of metastatic chondrosarcoma with extensive visceral and parietal pleural involvement is rare and infrequently noted in the literature. Palliative management with thoracentesis and IPC placement was complicated by the pervasive pleural calcification that prevented ultrasound imaging and made access to the pleural space difficult and dangerous. REFERENCE #1: Sureka B, Thukral BB, Mittal MK, Mittal A, Sinha M. Radiological review of pleural tumors. Indian J Radiol Imaging. 2013;23(4):313-320 DISCLOSURES: No relevant relationships by Robert Browning, source=Web Response, value=Grant/Research Support Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Robert Browning, source=Web Response, value=Consulting fee Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Robert Browning, source=Web Response, value=Consulting fee Removed 04/29/2021 by Robert Browning, source=Web Response No relevant relationships by Sean McKay, source=Web Response No relevant relationships by Philip Mullenix, source=Web Response No relevant relationships by Caitlin Nickens, source=Web Response No relevant relationships by John Shumar, source=Web Response

OUTCOMES OF PALLIATIVE CARE HOSPITALIZATIONS DUE TO END STAGE COPD

TOPIC: Palliative Care and End of Life Issues TYPE: Original Investigations PURPOSE: Palliative care is increasingly utilized among terminal comorbid illnesses like end stage Chronic Obstructive Pulmonary Disease (COPD) in the past several years. There is no recent population-based data available regarding outcomes of palliative care among end stage COPD patients and factors associated with it. We aimed to estimate temporal trends of outcomes and predictors of poor outcomes among palliative care hospitalizations due to end stage COPD. METHODS: We identified adult hospitalizations due to end stage COPD by using International Classification of Diseases (9th/10th Editions) Clinical Modification (ICD-9-CM/ICD-10-CM) from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. were identified. Palliative care encounters and other diagnosis of interests were identified by ICD-9/10-CM codes and comorbidities by Elixhauser comorbidity software. Our primary outcome was in-hospital mortality. We then utilized the Cochran Armitage trend test and multivariable survey logistic regression models to analyze temporal trends of outcomes. RESULTS: From 2007 to 2018 a total of 1,544,988 hospitalizations due to end stage COPD occurred, out of which 39,423 (2.6%) received palliative care. Among patients who received palliative care, overall In-hospital mortality was 23.2% and discharge to facilities was 27.1%. In trend analysis, in-hospital mortality has decreased (from 30.2% in 2007 to 18.6% in 2018; ptrend<0.01) and discharge to facilities increased (22.2% in 2007 to 29.2% in 2018; ptrend<0.01) among patients who received palliative care. In multivariable regression analysis after adjusting with confounding factors, rural hospital (OR 1.3; 95%CI 1.2 - 1.4; p<0.01), urban non-teaching (OR 1.2; 95%CI 1.1 - 1.3; p<0.01), uninsured/self-pay (OR 1.7; 95%CI 1.2 - 2.0; p<0.01), elective admission (OR 1.4; 95%CI 1.2 - 1.6; p<0.01) as well as concurrent conditions such as pneumonia, sepsis and other comorbidities were independently associated with higher in-hospital mortality among end stage COPD patients receiving palliative care. However African Americans vs Caucasians (OR 0.7; 95%CI 0.6 - 0.8; p<0.01), Mid-West region vs North-East region (OR 0.5; 95%CI 0.4 - 0.6; p<0.01) were associated with lower in-hospital mortality. CONCLUSIONS: We found that the in-hospital mortality rate among end stage COPD patients receiving palliative care has improved significantly between 2007-2018. Additionally, hospital teaching status, demographics, insurance status and secondary infections were associated with higher odds of mortality. CLINICAL IMPLICATIONS: Although in-hospital mortality in patients receiving palliative care during hospitalization due to end stage COPD has declined during the last decade, there are still several modifiable factors such as sociao demographics and hospital staus are associated with higher mortality. Our study highlights the need for better risk stratification and quality improvement in palliative care management of end stage COPD patients to further improve in-hospital outcomes. DISCLOSURES: No relevant relationships by Nawar Al janabi, source=Web Response No relevant relationships by Madiha Bari, source=Web Response No relevant relationships by Jasveen Kaur, source=Web Response No relevant relationships by Manmeet Kaur, source=Web Response No relevant relationships by Kinjalben Patel, source=Web Response No relevant relationships by Harshil Shah, source=Web Response No relevant relationships by FARAZ Siddiqui, source=Web Response No relevant relationships by Renan Soneghet, source=Web Response No relevant relationships by Astha Upadhyaya, source=Web Response

WHEN LESS IS MORE: UTILIZATION OF A MULTIDISCIPLINARY APROACH IN THE TREATMENT OF NATIVE TRIPLE-VALVE INFECTIVE ENDOCARDITIS

TOPIC: Palliative Care and End of Life Issues TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis (IE) is an insidious disease with significant hospital mortality rates. While many advances have been made to manage this disease, mortality rates still remain high. These rates worsen with the involvement of multiple valves. We report a case of native triple-valve IE were an appropriate interdisciplinary approach allowed the patient to focus on maximizing his desired outcomes. CASE PRESENTATION: An 85-year-old male with a past medical history of hypothyroidism presented with symptoms of generalized malaise, progressive dyspnea, intermittent blurred vision and left sided axillary pain for five months. Initial vitals showed tachycardia and patient was notably hypoxic. Blood cultures obtained on admission showed Streptococcus gallolyticus (bovis). Transthoracic echocardiography (TTE) revealed several vegetations involving the mitral, tricuspid and aortic valves (Figure 1-3). 4 months prior to admission, the patient had presented to the outpatient clinic with a syncopal episode. Work up at the time included a TTE which revealed a normal ejection fraction and no cardiac pathology. Given the development of new onset heart failure with cardiogenic shock in the setting of multi-valve infective endocarditis, a multidisciplinary team approach was taken. Cardiology, cardiothoracic surgery and palliative medicine work together to address the patient and his families goals. After informed discussion the patient decided against pursuing invasive cardiac surgery, and opted for palliative medical management. He was eventually transitioned to at home hospice. DISCUSSION: Triple valve endocarditis while extremely rare, it is associated with high rates of morbidity and mortality. According to existing literature (1,2), multi-valve IE has been recognized as an independent survival risk factor increasing mortality rate by 3% and a four fold higher rate of in-hospital mortality. The rate of complications such as congestive heart failure and acute renal failure are also higher with involvement of multiple valves, often warranting surgical intervention (3). In these situations the recovery is often prolonged with significant morbidity to the patients. In these situations it is best to approach clinical decision making with the patients goals of care in mind. Often in medicine we jump to aggressive treatments without fully taking the patients long-term goals in mind. Our treatments need to be evaluated to see if their outcomes and associated morbidities align with patients goals. With conversation based on these principles we can provide the patient with the highest level of benevolence, and ensure they receive the outcomes they truly wish. CONCLUSIONS: Triple valve surgery is extremely challenging and confers a poor prognosis. It is necessary to weight the risks and benefits of every intervention we take and make sure they align with the patients values and goals. REFERENCE #1: Sheikh, Azeem S, et al. "Triple-Valve Infective Endocarditis." British Journal of Cardiology, Apr. 2016, pp. 23–65., doi:10.5837/bjc.2016.015 REFERENCE #2: Kim N, Lazar JM, Cunha BA, Liao W, Minnaganti V. Multi-valvular endocarditis. Clin Microbiol Infect 2000;6:207–12. https://doi.org/10.1046/j.1469-0691.2000.00065.x REFERENCE #3: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:2440-92. 10.1161/CIR.0000000000000029 DISCLOSURES: No relevant relationships by Anand Buch, source=Web Response No relevant relationships by Tapan Buch, source=Web Response No relevant relationships by Ajinkya Buradkar, source=Web Response No relevant relationships by Pooja Kharbanda, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Humza Quadir, source=Web Response No relevant relationships by Ryan Quirk, source=Web Response No relevant relationships by Mohammed Ul Haq, source=Web Response

Assessing comprehensive care deficits in United States (U.S.) ovarian cancer programs to inform quality improvement initiatives.

256 Background: Ovarian cancer is the leading cause of gynecologic cancer mortality in the US. Given the high burden of disease and complexities in the provision of quality care, a multidisciplinary team approach is critical to optimal care delivery. In 2019, the Association of Community Cancer Centers (ACCC) launched a multiphase, stakeholder-driven initiative to improve care for this patient population. Results of a national survey of cancer programs to identify the needs of patients are reported here. Methods: A 20 question survey was developed by an expert steering committee including gynecologic oncologists, pathologists, genetic counselors, a nurse navigator, and cancer center administrators. The instrument was designed to collect data about cancer programs, key ovarian cancer patient needs, and barriers to and opportunities for improving ovarian cancer care. The online survey was open for participation for 4 weeks using the Qualtrics platform and distributed via email to ACCC and Society of Gynecologic Oncology members. Results: We received 26 total responses from Comprehensive Community (26%), NCI-Designed Comprehensive (22%), Academic Comprehensive (22%), and Integrated Network (13%) Cancer Programs. Annual ovarian cancer cases ranged from 22 to 190 (median: 50.5). 85% of programs has a multidisciplinary team for ovarian cancer and 61% were part of a referral network. On average, programs has 1.5 phase II and 2 phase III clinical trials currently available for ovarian cancer (all programs had at least 1 trial available). Palliative care and comprehensive symptom management was integrated into the first appointment (15%), integrated at the time of recurrence (4%), and most frequently, available by consult (81%). We assessed genetic testing practices at each program. Aggregated across programs, 79% of patients received germline multipanel testing, 71% germline BRCA only, 50% somatic multigene, and 51% somatic BRCA only. The frequency of consultations included: genetic counseling (75%), nurse navigation (75%), social work (50%), dietetics (40%), financial counseling (25%). Genetic evaluations were typically ordered by Gynecologic Oncology (88%), genetic counseling (4%), or both (8%). When asked what topic they would choose for a quality improvement project, genetic testing and counseling was the most frequent choice (46%), followed by clinical trials enrollment and availability (23%), multidisciplinary team care (19%), education on best practices (15%), palliative care (15%), and ancillary services (15%). Conclusions: Multidisciplinary care for ovarian cancer was common across a range of cancer programs but integration of palliative care, social work, dietetics, and financial counseling could be improved. Expanding clinical trials and genetic testing and counseling were the most frequently identified opportunities to improve ovarian cancer care.

Hypofractionated radiation therapy as palliative management for symptomatic and local control of advanced thoracic malignancies.

Radiation therapy plays an important role for symptom palliation for intrathoracic malignancies ineligible for curative-intent therapy. Limited data exists regarding the role of stereotactic body radiation therapy (SBRT) versus conformal radiation in intrathoracic tumors for palliation. We report the efficacy of hypofractionated RT (or palliative SBRT) in the symptom management and durable control of lung and non-lung intrathoracic tumors. We performed a retrospective review of ninety-two thoracic lesions across 76 patients who completed palliative SBRT with doses ranging 25-50 Gy in 5-10 fractions between 2009 and 2019. Symptoms (cough, chest pain, hemoptysis, shortness of breath) were assessed at consult and 1-6 months follow-up. Local control was evaluated using follow-up CT imaging via RECIST criteria. Descriptive statistics were used to evaluate symptom palliation and Kaplan-Meier method to analyze local control. Of primary lung (Cohort P) lesions, 40% showed stable symptoms, 30% never developed symptoms, and 19% showed symptom relief. CT imaging 1-6 months post-SBRT showed 91% with partial response (PR) or stable disease (SD) in Cohort P and 87% with PR or SD in metastatic (Cohort M) lesions. In patients with initial PR/SD, local control until death was achieved in 71% of Cohort P and 84% of Cohort M. Of our symptomatic patients (Cohort S), 98% showed no symptom progression post-radiotherapy. All patients with hemoptysis at presentation achieved hemostasis post-radiotherapy. Palliative SBRT has the advantage of higher biologic dose without protracted course for patients with limited prognosis. Patients showed significant symptom palliation and long-term local control. Palliative SBRT represents a reasonable treatment modality for incurable thoracic malignancies.

Real-world evidence on first- and second-line palliative chemotherapy in advanced pancreatic cancer.

In spite of recent diagnostic and therapeutic advances, the prognosis of pancreatic ductal adenocarcinoma (PDAC) remains very poor. As most patients are not amenable to curative intent treatments, optimized palliative management is highly needed. One key question is to what extent promising results produced by randomized controlled trials (RCTs) correspond to clinically meaningful outcomes in patients treated outside the strict frames of a clinical trial. To answer such questions, real-world evidence is necessary. The present paper reviews and discusses the current literature on first- and second-line palliative chemotherapy in PDAC. Notably, a growing number of studies report that the outcomes of the two predominant first-line multidrug regimens, i.e. gemcitabine plus nab-paclitaxel (GnP) and folfirinox (FFX), is similar in RCTs and real-life populations. Outcomes of second-line therapy following failure of first-line regimens are still dismal, and considerable uncertainty of the optimal management remains. Additional RCTs and real-world evidence studies focusing on the optimal treatment sequence, such as FFX followed by GnP or vice versa, are urgently needed. Finally, the review highlights the need for prognostic and predictive biomarkers to inform clinical decision making and enable personalized management in advanced PDAC.

Endoscopic balloon dilation for management of stricturing Crohn's disease in children.

BACKGROUNDCrohn’s disease (CD) has a multitude of complications including intestinal strictures from fibrostenotic disease. Fibrostenotic disease has been reported in 10%-17% of children at presentation and leads to surgery in 20%-50% of cases within ten years of diagnosis. When symptoms develop from these strictures, the treatment in children has primarily been surgical resection. Endoscopic balloon dilation (EBD) has been shown to be a safe and efficacious alternative to surgery in adults, but evidence is poor in the literature regarding its safety and efficacy in children.AIMTo evaluate the outcomes of children with fibrostenosing CD who underwent EBD vs surgery as a treatment.METHODSIn a single-center retrospective study, we looked at pediatric patients (ages 0-18) who carry the diagnosis of CD, who were diagnosed after opening a dedicated Inflammatory Bowel Disease clinic on July 1, 2012 through May 1, 2019. We used diagnostic codes through our electronic medical record to identify patients with CD with a stricturing phenotype. The type of intervention for patients’ strictures was then identified through procedural and surgical billing codes. We evaluated their demographics, clinical variables, whether they underwent EBD vs surgery or both, and their clinical outcomes.RESULTSOf the 139 patients with CD, 25 (18%) developed strictures. The initial intervention for a stricture was surgical resection in 12 patients (48%) and EBD in 13 patients (52%). However, 4 (33%) patients whom initially had surgical resection required follow up EBD, and thus 17 total patients (68%) underwent EBD at some point in their treatment process. For those 8 patients who underwent successful surgical resection alone, 4 of these patients (50%) had a fistula present near the stricture site and 4 (50%) had strictures greater than 5 cm in length. All patients who underwent EBD had no procedural complications, such as a perforation. Twenty-two (88%) of the treated strictures were successfully managed by EBD and did not require any further surgical intervention during our follow up period.CONCLUSIONEBD is safe and efficacious as an alternative to surgery for palliative management of strictures in selected pediatric patients with CD.

Interventions for palliative symptom control in COVID-19 patients.

Interventions for palliative symptom control in COVID-19 patients.

Medicinal plants as immune booster in the palliative management of viral diseases: A perspective on coronavirus

AbstractMedicinal plants are not only popular for their ample store of active ingredients but also boast of several pharmacological properties including the modulation of components of the immune system. An adequate immune response is vital in counteracting the unwanted activities of pathogens such as bacteria, protozoa, and viruses. Some diseases caused by viral pathogens such as measles, chickenpox, Ebola, and human immunodeficiency virus may result in death or dire consequences in mammals with inadequate immunity. Ever since coronavirus disease 2019 (COVID‐19) boisterously announced itself to the world in December 2019, there has been a surge in the number of researches targeting medicinal plants as candidates for a potent vaccine and antiviral drug. COVID‐19 is a member of a family of coronaviruses that have been responsible for past pandemics such as the Middle East respiratory syndrome and severe acute respiratory syndrome outbreaks. However, the nascent COVID‐19 defeated existing pharmaceutical advances and nonpharmacological measures such as high personal hygiene, physical distancing, and lockdown to stop the vicious mortality arising from the viral outbreak. Consequently, the battle against this virus relies majorly on a vibrant immune system. It is therefore imperative to promote interest in the use of medicinal plants that will significantly assist in the management of COVID‐19 infection by boosting body's immune responses or arresting symptoms/molecules associated with COVID‐19 pathogenesis. This review underscores the need for the exploration of plant‐based agents that may prove effective in fighting COVID‐19 based on scientific evidence of their positive immunomodulatory effects.

Small bowel obstructions and gynecologic malignancies: conservative, operative and palliative management

Objectives: Small bowel obstructions (SBO) are common in women with gynecologic malignancies. Conservative management is typically the first-line treatment for these patients. However, despite similar initial clinical presentations, some women ultimately require acute surgical interventions or palliative procedures to relieve symptoms. We aimed to characterize and compare these three management options (conservative management, acute intervention and palliative procedures) in order to better understand how to best approach treatment, individualize management, and optimize patient outcomes. Methods: Following IRB approval, ICD-10 codes were utilized to retrospectively identify women with gynecologic malignancies hospitalized for SBO from 2006-2019 at a single academic center. Clinical, treatment, and outcome data were collected. Risk factors were reported using descriptive statistics and compared between treatment groups using Chi-Square/Fisher's exact test for categorical risk factors and Mann-Whitney U test for continuous risk factors. Results: We analyzed 288 admissions from 253 unique patients, of which 229 patients (90.5%) had one admission and 24 (10.4%) had more than one admission. The majority had ovarian cancer (60.4%). Of the 288 admissions, 163 (56.6%) resolved with conservative management, 60 (20.8%) underwent acute surgical intervention, and 65 (22.6%) underwent palliative gastrostomy tube placement. Active cancer on presentation (p=0.005), number of comorbidities (p=0.009), type of obstruction (p=0.001), number of prior chemotherapy lines (p=0.03), platinum resistance (p=0.012), chronic opioid use (p=0.006), and placement of nasogastric tube on admission (p=0.022) were significantly different among the three groups. In pairwise comparison, patients undergoing acute surgical intervention had a lower mean number of comorbidities (1.98 versus 2.66, p=0.017) and were more likely to have a high grade versus partial bowel obstruction (p Conclusions: Risk factors for surgical intervention can aid in counseling, medical optimization, and treatment decisions for patients at high risk for failure of conservative management of SBO. In this cohort, patients with high grade obstruction and > 2 medical comorbidities were statistically more likely to fail conservative management, which may suggest need for earlier surgical intervention. Future studies evaluating the management of SBO in patients with gynecologic malignancies across institutions may help in developing a treatment algorithm for this patient population.

DO NOT Remove the Catheter: A Case Report on Pediatric Palliative Pain Management with an Erector Spinae Plane Block

BACKGROUND: Erector spinae plane block (ESB) is a novel fascial plane regional anesthetic technique for pain management. The case report highlights the need for multidisciplinary education on regional nerve blockade in pediatric palliative medicine. CASE REPORT: The patient was a 5-year-old girl with relapsed metastatic Wilms tumor who presented with recurring malignant pleural effusion, necessitating chest tube insertion. She received a thoracic ESB via catheter to successfully manage uncontrolled pain. Radiation was needed, but radiation providers refused to continue ESB treatment, erroneously citing possible interactions between ESB and radiation therapy. The catheter was removed, and the patient suffered from complications before passing away. CONCLUSION: Interdisciplinary education on regional nerve blockade in pediatrics is imperative to prevent premature removal of anesthetic catheters during treatment, thereby causing unnecessary pain after risk of placement is undertaken. Further, we propose that the ESB is feasible for palliative pain management despite patient age and size. KEY WORDS: Acute pain anesthesiology, erector spinae plane block, palliative medicine, pediatric anesthesia, regional anesthesia