Palliative Patients Research Articles

MS O02 - OGC An audit of waiting times of the oesophagogastric cancer diagnostic pathway at a high-volume, tertiary centre

Abstract Background The oesophagogastric cancer (OGC) staging pathway is extensive, contributing to prolonged waiting times from referral to treatment. NHS England guidance details the ideal timeframe from referral to finalisation of the patient’s treatment plan and stipulates a time of 21 days from OGD to communication of the treatment plan to the patient. This audit aims to compare pathway times at a tertiary cancer centre, which accepts referrals from seven different hospitals, to the current NHS target and further stratify pathway times according to patient characteristics and referring hospitals. Method Data was collected using a prospectively collected database of OGC patients who underwent staging investigations at the tertiary centre between October 2022 and October 2023. The primary outcome was OGD to communication of the treatment plan. Secondary outcomes included time from OGD to first staging investigation and the proportion of patients that had a next-day computed tomography (CT) scan. Outcomes were stratified to investigate inter-hospital variation and the effect of curative status and tumour location. Data was expressed as median and interquartile range (IQR) for continuous data or n (%) if categorical. Results 263 patients were included in this audit with a median age of 69.0 (IQR 61.5-77.0). 13.8% of patients satisfied the target time of 21 days from OGD to communication of treatment plan. Curative patients had a longer median pathway time than palliative patients (49.0 vs 35.0 days), whereas oesophageal and gastric cancer patients had similar pathway times (44.0 vs 44.5 days). Patients diagnosed at the tertiary centre had a faster time from OGD to first staging investigation than patients diagnosed at non-specialist centres. Only 13.3% of patients had a next-day CT scan following their OGD (median time 5.0 days). Conclusion The OGC staging pathway is considerably slower than the target. Faster pathway times in palliative patients can be attributed to many of these patients not requiring further staging post-CT. Potentially, targets should be re-evaluated to distinguish between palliative and curative patients. The faster staging process at the central hospital may be explained by more regular clinics run by specialist clinicians and the prompt requesting of staging investigations without awaiting MDT discussions. Alongside increasing the proportion of next-day CT scans, these factors must be addressed to streamline the entire pathway.

Prolonged length of stay and associated factors among emergency department patients in Ethiopia: systematic review and meta-analysis.

The duration between a patient's arrival at the Emergency Department (ED) and their actual departure, known as the Emergency Department Length of Stay (EDLOS), can have significant implications for a patient's health. In Ethiopia, various studies have investigated EDLOS, but a comprehensive nationwide pooled prevalence of prolonged EDLOS, which varies across different locations, is currently lacking. Therefore, the objective of this systematic review and meta-analysis is to provide nationally representative pooled prevalence of prolonged EDLOS and identify associated factors. In this study, we conducted a comprehensive systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. We conducted a thorough search of numerous international databases, including PubMed/Medline, SCOPUS, Web of Science, and Google Scholar. The primary outcome was the prevalence of prolonged EDLOS. The secondary outcome was factors affecting the EDLOS. Random-effects model was used to since there was high heterogeneity. We also conducted subgroup analysis and meta-regression to investigate heterogeneity within the included studies. To assess publication bias, we used Egger's regression test and funnel plots. All statistical analyses were performed using STATA version 17.0 software to ensure accurate and reliable findings. We have identified eight articles that met our inclusion criteria with a total sample size of 8,612 participants. The findings of this systematic review and meta-analysis indicate that the pooled estimate for the prevalence of prolonged EDLOS is 63.67% (95% CI = 45.18, 82.16, I2 = 99.56%, P = 0.0001). The study identified several significant factors associated with prolonged EDLOS, including patients admitted to overcrowded emergency departments (OR = 5.25, 95% CI = 1.77, 15.58), delays in receiving laboratory findings (OR = 3.12, 95% CI = 2.16, 4.49), and delays in receiving radiological results (OR = 3.00, 95% CI = 2.16, 4.16). In this review, the EDLOS was found to be very high. Overcrowding, delays in laboratory test findings, and delays in radiology test results make up the factors that have a statistically significant association with prolonged EDLOS. Given the high prevalence of prolonged EDLOS in this review, stakeholders should work to increase the timeliness of ED services in Ethiopia by proper disposition of non-emergency palliative patients to the appropriate destination, and implementing point-of-care testing and imaging.

The impact of in-house education on staff confidence in delivering palliative and end-of-life care: a service evaluation.

Palliative and end-of-life care (EoLC) education is available to all community and hospital healthcare staff in one NHS trust in the north-east of England. It is also available to care home and domiciliary care staff within the geographical area of the trust. This service evaluation assessed the effect of current in-house education on staff confidence levels in delivering palliative and EoLC. It also examined staff perceptions of how attendance at these courses impacted on the palliative and EoLC patients receive across the locality. A mixed-methods approach was undertaken. Anonymous data were collected via surveys (n=238) sent out in March 2023 covering educational courses that were delivered from 1 January to 31 December 2022 with a 13% response rate. Quantitative data were analysed using descriptive statistics. Qualitative data were explored using Braun and Clarke's (2012) six-stage approach to thematic analysis. A second staff member was asked to review the data to increase the trustworthiness of the study. Staff confidence levels in delivering palliative and EoLC increased by 19% (somewhat confident) and 23% (extremely confident) following attendance at trust education. Staff perceived that those patients received better palliative and EoLC as a result their attendance at these courses. The qualitative data identified five main themes: symptom control, psychological support, holistic care, patient advocacy, and advance care planning. Limitations of the study included the low survey response rate and lack of exploration of patient/carer perceptions directly. Palliative and EoLC education can increase staff confidence levels in care delivery and, as perceived by staff, results in better care for patients receiving palliative and EoLC. These findings provide evidence for the trust to consider making palliative and EoLC training mandatory, which could also be considered more widely regionally and nationally.

Comparison of resuscitation intervention utilization in the emergency department by palliative care eligible patients between cancer and non-cancer

Resuscitation interventions are procedures for managing clinical deterioration in patients with life-threatening conditions by securing the airway, maintaining breathing, or supporting circulation. Little is known about differences in the use of resuscitation interventions and the characteristics of patients eligible for palliative care in the emergency department. The objectives of this study are to compare resuscitation interventions in the emergency department between patients with cancer and non-cancer palliative care eligibility. A retrospective cohort study was conducted by reviewing the medical records of the palliative care eligible patients who visited the emergency department of one university hospital between January and June 2019. Among the 956 visits (13.7%) by palliative care eligible patients of 7000 random visits, 480 were patients with cancer (50.2%), and 476 were non-cancer patients (49.8%). The overall median age was 72, and 54.1% were female. The mortality rates in the following year were 35.0% for patients with cancer and 18.7% for non-cancer illnesses. The patients with cancer and non-cancer received prior palliative care at 7.3% and 0.8% (p < 0.001) and initiated palliative care at the emergency department at 6.3% and 2.7%, respectively (p = 0.008). The non-cancer patients utilized overall resuscitation interventions 1.7 times more than the cancer patients (aOR = 1.7, 95% CI = 1.0–2.6, p = 0.030). For the palliative care eligible patients in the emergency department, patients with cancer and non-cancer significantly differed in their characteristics. Patients with non-cancer received more resuscitation interventions than patients with cancer.

Expected benefits and concerns regarding virtual reality in caring for terminally ill cancer patients – a qualitative interview study

BackgroundMany palliative cancer patients require inpatient hospital treatment for medical reasons, which contrasts their frequent desire to be at home. Virtual reality (VR) could be a way of bringing the home environment closer to them. First observations have shown benefits from VR for inpatients in palliative care. The aim of this qualitative, descriptive study was to explore the expectations of in-patients suffering from incurable cancer and their relatives about VR, in particular individualized VR images of the patients’ own home.MethodsSemi-structured interviews with inpatients suffering from incurable cancers and their relatives in three medical settings (palliative care, hematology, radiotherapy) of a German university hospital. Qualitative content analysis about expected benefits and concerns regarding VR-videos showing their private home; defining the main topics deductively and the subcategories inductively. We also assessed the patients’ subjective perspective on their remaining time to live to estimate the impact of double awareness on the results. The Patient Advisory Board informed the study protocol and conduct.ResultsWe interviewed 15 patients (8 men; age M = 63.4, SD = 11.34; range 39–82) under palliative care, and four relatives. We organized the interview content in 6 themes (general interest, desired content, non-desired content, expected benefits, concerns, and irregularities) and 26 sub-themes. Most patients and relatives were interested in using VR during hospital treatment. They often preferred viewing nature or tourist sites over seeing their home or family. Reasons could be linked to privacy concerns and the general desire for distraction from the current situation that they specified with their expectation of well-being, a break from the patient-experience, the pursue of curiosity, and the VR evoking fond memories.ConclusionVR seems to be of interest for palliative cancer patients, especially as distraction and relief from their illness. The desired content can be very different, so a choice from a selection of VR-content should be made available. If patients want to see videos of their own home, recordings by relatives instead of study or hospital staff seem to meet the need for privacy.Trial registrationRegistered at Deutsches Register Klinischer Studien; registration number: DRKS00032172; registration date: 11/07/2023. https://drks.de/search/de/trial/DRKS00032172.

Impact of Myc-Altered Pathology on Radiotherapy Efficacy Among Patients with Relapsed/Refractory Large-B Cell Lymphoma: A Collaborative Study by XXX: Impact of double hit pathology on RT efficacy.

Presence of MYC and BCL2 translocations (i.e. double-hit lymphoma, DHL) in large B-cell lymphoma (LBCL) is associated with reduced chemosensitivity, but less is known on its impact on radiotherapy (RT) efficacy. Patients with LBCL that received their first course of RT for relapsed/refractory (r/r) disease between 2008-2020 were eligible if there was adequate pathologic evaluation to be categorized as DHL versus non-DHL as per WHO (5th edition). Separate analyses were conducted by treatment intent. Predictors for response (complete and partial) and local recurrence (LR) were evaluated using Cox regression analysis. LR analysis was restricted to curative-intent patients to ensure adequate follow-up. 383 patients (102 DHL, 281 non-DHL, 44% curative) were treated to 447 sites. Median time from diagnosis to RT was 11.6 months, with 38.7% patients having primary chemorefractory disease, 37.4% having received >2 lines of systemic therapy, and 24% status post stem cell transplant. Median biological equivalent dose (alpha/beta 10) was 28 Gy (range 3.2-60.0) for palliative and 46.9 Gy (range 6.4-84.0) for curative-intent patients. With a median follow-up of 41.1 and 41.5 months among curative and palliative patients, respectively, response was high (81.1% curative, 60.1% palliative). On univariate analysis, DHL pathology was not associated with RT response in either curative or palliative patients. Among curative patients, 2-year LR rate was 38.8%. On multivariable analysis, DHL pathology was associated with a 2 times higher risk of LR (95% CI 1.05-3.67,p=.03), with a crude LR rate of 42.9% (DHL) versus 28.9% (non-DHL). RT was well tolerated with low rates of grade 3 or higher acute toxicity (1.8% curative, 2.9% palliative). Relapsed/refractory LBCL remains radioresponsive with 60-80% response rate to RT. While DHL pathology does not appear to influence RT response, its presence is associated with higher rates of local recurrence, suggesting it may be more radioresistant.

Dealing with dichotomies in health care: Case reports

ABSTRACT Dichotomies with respect to medical orientations and public health have been common in the past and even in the present probably orchestrated by the traditional versus modern medical concepts that became eternal arena for disquiet in the healing world of many countries. In public health, the so-called technology tradition was especially dominant which assumed the power of technology and the paternalistic ‘managerial mode’ regarding disease control programs. Such a ‘managerial perversion’ has demolished the positivity of primary health care as well as the social determinants framework. It is important to consider cultural background, the belief systems and perceptions of the people in shaping the health behaviour of the people. We are presenting here two case reports on distinct scenarios in order to show the conceptual problems with respect to the notion of dichotomies and the linkages with health. These are based on our empirical explorations using qualitative methodologies. The first case is on non-communicable diseases in a tribal society in Kerala and the second one on utilization of Traditional Complementary and Alternative Medicine (TCAM) among palliative cancer patients from a district in Kerala. It is seen that as new problems emerge or when people struggle with diseases as presented in the two case reports, they tend to depend on the positivity of the deeply entrenched cultural artefacts in combination with modern systems and they tend to bridge the dichotomies rationally instead of viewing them retrograde. It is necessary to examine the reasons for engaging in such syncretic health behaviour which could be popular realizations on the positive and negative features of both health orientations. This approach of the people could be used effectively for managing such health problems in the community.

Pain in palliative cancer patients – Analysis of the German National Palliative Care Registry

Palliative care aims to improve the quality of life in patients with progressive diseases such as cancer. Effective cancer pain management is a major challenge of palliative treatment. Empirical data on the prevalence of cancer pain, the efficiency of pain treatment and influencing factors are scarce. Here, we investigated pain in cancer patients treated on inpatient palliative care wards in Germany. N = 4779 data sets provided by the German Palliative Care Registry from yearly evaluation periods between 2015 and 2020 were included. Pain ratings were assessed by professionals through a checklist of symptoms and problems (HOPE-SP-CL). More than half of the included patients suffered from moderate/severe pain at the beginning of inpatient palliative care and in 71% of these patients, pain relief was achieved at the end of inpatient treatment. Pain intensity, depression and ECOG performance status at admission were weak predictors of later pain relief. The highest pain intensity at the beginning and least pain relief were found in patients with bone and cartilage cancer. The highest percentage of adequate pain control (81%) was seen in 2020. Data from the German Palliative Care Registry confirmed that although increasingly better addressed over the years, insufficiently controlled cancer pain remains a challenge for palliative care units. Patient-specific (e.g. psychological comorbidity) and cancer-related (e.g. bone or cartilage cancer) risk factors for poor pain treatment underline the need for individualized multimodal pain management including psychological support.

Knowledge, attitudes, practices of cancer palliative care and their associated factors among nursing officers in Apeksha Hospital, Maharagama

Introduction: Nursing officers, having a good knowledge, favourable attitudes, and correct practices in cancer palliative care uplift patient’s quality of life. Objectives: To describe the level of knowledge, attitudes, practices of cancer palliative care and associated factors among the nursing officers in Apeksha Hospital, Maharagama. Methods: A descriptive cross-sectional study was carried out among 252 participants with more than one year of work experience at Apeksha Hospital, Maharagama. Stratified sampling technique was adopted to select the nursing officers from different wards. Data were collected using a validated self-administered questionnaire. Sum of points of each participant and the percentage was calculated. Depending on the mean score they were categorized into groups accordingly. Data were analysed initially by a descriptive analysis and then by Chi square test using SPSS software version 26. P&lt;0.05 was the significance level. Results: Response rate was 70. %. The mean age of the study participants was 32.9 (SD=6.55) years. The majority (59.5%) had good knowledge, 53.2% had favourable attitudes and 54% engaged in correct practices. Mean knowledge score was 26.4 (SD=3.44). Nurses above 30 years of age, married and having more than 10 years’ experience had significant association with knowledge (p&lt;0.05). Most of the participants who had good knowledge had correct practices (p&lt;0.001). Most of the participants those who had favourable attitude had correct practices (p&lt;0.001). Association of level of knowledge and attitude was not found to be statistically significant (p=0.109). Conclusion: The majority of the nurses had a good knowledge, favourable attitudes and were engaged in correct practices in palliative care. There is a significant association between the year of experience and the nurses’ knowledge on palliative care. Having a good knowledge and favourable attitude on palliative care were positive factors for correct practices.Keywords: Knowledge, Attitude, Practices, Cancer palliative care, Nurses

Longitudinal Study of Bereavement Outcomes Among Palliative Caregivers Mourners: Psychological Profiles in Prolonged Grief and Psychopathology.

Prolonged grief (PG) is a mental health condition characterized by severe distress following a loss. This study examines the roles of attachment styles, social support, stressful life events (SLEs), and pre-existing psychopathology in predicting PG and post-bereavement psychopathology among 74 caregivers of palliative patients. Using validated assessment tools, the study employed hierarchical regression and fuzzy-set qualitative comparative analysis (fsQCA) to identify predictors of prolonged grief and psychological outcomes over six months. Results showed that pre-existing psychopathology and PG risk predicted post-bereavement psychopathology, though not PG itself. Low social support and high SLEs were linked to worse outcomes, while strong social support and low stress predicted positive outcomes. These findings highlight the importance of multiple interacting factors in understanding grief and emphasize the need for interventions that enhance social support, manage stress, and address mental health conditions to reduce psychological distress in bereaved caregivers.

Decrease in Primary Caregivers' Quality of Life During the Care of a Relative with Palliative Care Needs: A Prospective Longitudinal Study.

The quality of life is a complex concept that is insufficiently assessed in clinical practice. It is influenced by different factors, as follows: the individual's characteristics, personal values and beliefs, physical and mental state, and relationship to other members of their community. The quality of life of the primary caregiver influences their health and the quality of their care interventions. This study aims to investigate how the quality of life of caregivers changes during palliative patients' care. This is a prospective longitudinal study that assesses the different aspects of the quality of life of primary caregivers who care for patients with palliative needs. The tool used in this study was the Medical Outcomes Scale-Short Form 36 (MOS-SF36). This study included 140 caregivers, of which 63 were involved in the care of patients with cancer and 77 were involved in the care of patients with non-oncological diseases. Almost 9 out of 10 caregivers were a family member of the patient and over two-thirds of these were women. The caregivers of patients with non-malignant diseases had a decreased quality of life in the following aspects: limitations in their usual role due to emotional problems, social functioning, energy, and their perception of their general health. In the group of oncological patients, the caregivers displayed limitations in their daily role due to physical health, emotional problems, and social functioning. The large number of responsibilities, the long time spent caring, and the uncertainty about the evolution of the disease as well as the marginalization and lack of time for oneself are some of the elements that increase caregiver burden. Along with this, the quality of life of caregivers decreases significantly in different aspects, such as physical, psycho-emotional, and social, with the perception of deteriorating general health.

Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis

Background and aimsRelief of cholestasis in hilar cholangiocarcinoma is commonly undertaken in both curative and palliative treatment plans. There are numerous open questions with regard to the ideal biliary drainage strategy – including what constitutes clinical success (CS). In the existing data, curative patients and patients from the Western world are underrepresented.Patients and methodsWe performed a retrospective analysis of patients with complex malignant hilar obstruction (Bismuth-Corlette II and higher) due to cholangiocarcinoma who underwent biliary drainage at a German referral center between 2010 and 2020. We aimed to define CS and complication rates and directly compare outcomes in curative and palliative patients.Results56 curative and 72 palliative patients underwent biliary drainage. In patients with curative intent, CS was achieved significantly more often regardless of what definition of CS was applied (e.g., total serum bilirubin (TSB) < 2 mg/dl: 66.1% vs. 27.8%, p = < 0.001, > 75% reduction of TSB: 57.1% vs. 29.2%, p = 0.003). This observation held true only when subgroups with the same Bismuth-Corlette stage were compared. Moreover, palliative patients experienced a significantly greater percentage of adverse events (33.3% vs. 12.5%, p = 0.01). Curative intent treatment and TSB at presentation were predictive factors of CS regardless of what definition of CS was applied. The observed CS rates are comparable to published studies involving curative patients, but inferior to reported CS rates in palliative series mostly from Asia.ConclusionsBiliary drainage in complex malignant hilar obstruction due to cholangiocarcinoma is more likely to be successful and less likely to cause adverse events in curative patients compared to palliative patients.

Partially Ablative Body Radiation Therapy: A Widely Applicable Planning Technique for Palliation of Locally Advanced Unresectable Tumors

Patients with locally advanced, bulky, and unresectable tumors frequently exhibit frailty and endure symptomatic burdens arising from the mass effect of their tumors. Conservative approaches may often fail to provide symptomatic benefits in relatively radioresistant, slower-growing tumors such as sarcomas. A novel technique termed partially ablative body radiation therapy (PABR) administers a highly centralized ablative dose through the utilization of a simultaneous integrated boost while delivering a low and safe palliative dose to the peripheral regions of tumors. The purpose of this paper was to describe a widely applicable radiation therapy protocol in detail for the PABR technique, of which clinical results are available in previous work.7 In summary, a PABR prescription of 20 Gy in 5 fractions is applied to the planning target volume and is planned for 95% of the volume to be covered by 95% of the prescribed dose. A dose of 50 Gy is planned to the boost target volume, with an allowed maximum dose of up to 65 to 70 Gy, using volumetric modulated arc therapy. Daily Cone-Beam Computed Tomography images are used for delivery verification and imaging study. The centrally located volume exceeding 50 Gy effectively achieved the desired outcomes of symptom relief and tumor size reduction. The PABR approach is widely accessible and can be readily implemented in a routine clinical setting to address a pressing need for the challenging palliative patient cohort.

The impact of home parenteral support on phase angle and functional mass change in palliative cancer patients with chronic intestinal failure (TYPE 3)

The impact of home parenteral support on phase angle and functional mass change in palliative cancer patients with chronic intestinal failure (TYPE 3)

The association between glim-diagnosed malnutrition and survival: Findings from a large cohort of palliative cancer patients

The association between glim-diagnosed malnutrition and survival: Findings from a large cohort of palliative cancer patients

Impact on ambulatory palliative appointment lead times by standardizing scheduling protocols based on cognitive computing models.

62 Background: Although palliative care is available across the United States, access continues to remain variable. In Texas, only 52% of hospital systems have palliative services. As a result, optimizing existing systems is critical to providing timely services to this vulnerable population. The Supportive Care Services Clinic at University Health in San Antonio, TX provides ambulatory palliative services to patients including physical and psychosocial symptom management and care coordination. For the period April 1, 2023 to June 30, 2023 average lead times for new palliative patient visits (NPPV) and hospital consult discharge visits (HCDV) was 53 days and 39 days respectively. The aim of this project was to decrease the lead times for NPPV and HCDV through standardization of scheduling criteria. We hypothesized that by applying a scheduling protocol utilizing cognitive computing models (CCM) calculating readmission risk scores to prioritize referrals, we could reduce appointment lead times. Methods: During the implementation phase, we developed referral triage criteria to prioritize patients on a scheduling wait list, including patients who were at higher risk of hospitalization or rapid decline based on CCM readmission risk scores calculated within the electronic medical record. Patients were assigned to next available in template. If a cancelation occurred, patients were pulled forward and vacancy was filled based on priority score. Results: For the initial post-implementation period between September 1, 2023 and November 30, 2023 NPPV average lead time was 47 days which was a reduction of 11% from baseline. The average lead time for HCDV was 33 days which was a reduction of 15% from baseline. In a second follow-up period from February 1, 2024 to April 30, 2024, the average lead time of NPPV was 22 days, a 58% decrease from baseline. The average lead time for HCSV was 24 days which was a significant reduction (p-value = 0.011) of 38% from the pre-implementation baseline. Conclusions: Utilization of CCM risk scores to triage NPPV and HCDV significantly reduced the lead times and resulted in more timely services for critical patients. We also noted increased template utilization. Future projects aim to study the effects of scheduling protocols on template utilization, cancellation rates, no-show rates, readmission rates and other health care utilization. Palliative appointment lead times. April-June 2023 Sept-Nov 2023 Feb-Apr 2024 Total Pt Seen 292 364 534 Avg Lead Time (d) 41 38 29 New Patient New Patient New Patient Completed 66 82 74 Avg Lead Time (d) 53 47 22 Hospital Discharge Hospital Discharge Hospital Discharge Completed 27 28 25 Avg Lead Time (d) 39 33 24

Case Series of Akathisia in Palliative Medicine: Patient Perspective and Efficacy of Procyclidine in Diagnosis and Management.

Akathisia is a disturbing, reversible but under-diagnosed extrapyramidal side effect of medications used in palliative medicine. We assessed patients' subjective experience of akathisia and response to procyclidine, an anticholinergic used to treat extrapyramidal effects. We also aimed to discuss future areas of research and alternatives to akathisia-causing medications. Suitable patients were retrospectively identified by palliative medicine physicians in a tertiary hospital and a chart review was undertaken. Information gathered included the account of their experience of akathisia, use of inciting medications, treatment, and outcome. 20 patients were identified, 12 females, 8 males. Mean number of days on the inciting drug(s) to onset of akathisia symptoms was 18.1. Mean number of days from commencing inciting drug(s) to diagnosis was 20.9. Patients' descriptions revealed similarities including feeling "locked in" and a need to constantly move. One patient described a "glass coffin" enclosing her. 16 patients had full response to treatment with procyclidine, 3 had partial response requiring up-titration of dosing, response was not documented in 1. Akathisia is an elusive symptom that can have dramatic reversibility when treated. Lack of recognition causes unnecessary patient suffering. Procyclidine appears to aid diagnosis and be an effective treatment. Protocols to reduce incidence and guide diagnosis and management are proposed. Further studies are required, in which subjective outcome measures are used and medications to treat akathisia are studied. Recognition remains challenging, causing significant distress for palliative patients, for whom quality of life is paramount.

Medical and social aspects of euthanasia of palliative patients in the Netherlands, Belgium and Germany

In the palliative and hospice medicine of Ukraine, there are a number of unresolved legal and organizational problems that stand in the way of a dignified existence of hopelessly ill patients in the last days and months of their lives. First of all, these are unresolved issues with the coverage of treatment and care of a sufficient number of categories of patients: palliative care is provided mainly to patients with oncological, cardiovascular and neurological profiles of treatment. Secondly, it is the lack of adequate analgesia for a significant number of inpatients and the vast majority of patients receiving treatment at home. Availability of recently legalized medical cannabis remains low for palliative care patients, and palliative care euthanasia is not legalized. In our previous research, we found out that Ukrainian society is not ready for a dialogue about the need to legalize euthanasia, and that the best model of preparing society for euthanasia is the Canadian one, which is based on a comprehensive study of the opinions of the general public and direct participants of the Medical Assistance in Dying (MAiD), as well as on the implementation of decisions federal court. The article is devoted to legal procedures and socio-medical aspects of euthanasia and MAiD in the Netherlands, Belgium and Germany. Certain aspects of legalization, its context and circumstances, compared with the conditions of Ukraine. The article is an original theoretical study performed using the method of systematic analysis, comparative and bibliosemantic methods. Note that we are clarifying the terminology of the previous stages of the study: MAiD is performed by the patient himself, euthanasia is performed by the doctor. In our opinion, Ukraine needs the legalization of euthanasia and MAiD for all age categories, and with the implementation of special additional consent procedures for adult incapacitated patients. In the experience of the countries of the current comparison, we paid special attention to the prevention of abuses in the implementation of these procedures, in the conditions of frequent disregard for the norms of the law since the beginning of the war. Keywords: palliative and hospice care, suicides of palliative patients, Medical Assistance in Dying, right to life, right to die.

Adenosquamous Carcinoma of the Lung: Survival, Radiologic Findings, PD-L1, and Driver Mutations.

Background: Adenosquamous carcinoma of the lung (ASC) is a rare non-small-cell lung cancer (NSCLC) subtype combining components of squamous cell carcinoma (SCC) and adenocarcinoma (AC). Data on ASC, particularly in Caucasian populations, are limited. Methods: We reviewed clinicopathological and radiological characteristics of ASC patients diagnosed between 1996 and 2023. Patients were classified into AC-predominant ASC (AC-ASC) and SCC-predominant ASC (SCC-ASC) groups for analysis. Results: Among the 66 patients included, the median overall survival was 41.7 (95% CI, 25.0-54.4), while it was 48.1 (95% CI, 27.3-88.0) in patients treated with curative surgery (n = 44) and 15.3 (95% CI, 6.5-42.6) months for palliative patients (n = 22). The five-year survival rates were 39% and 26%, respectively. Recurrence occurred in 43% of stage I patients and was associated with worse survival (HR 3.303 (95% CI, 1.10-9.89) p = 0.033). AC-ASCs (n = 17) more frequently showed air-bronchogram (p = 0.002) and pleural effusions (p = 0.054) compared to SCC-ASCs (n = 26). SCC-ASCs exhibited more vascular invasion (p = 0.006) and PD-L1 values between 1 and 49% (TPS) (p = 0.032). The subtype did not influence survival. EGFR and ALK alterations were found in 17% and 2% of patients, respectively. Conclusions: Despite early-stage disease, ASC patients had a high recurrence rate, associated with worse survival. Clinicopathologic differences between AC-ASCs and SCC-ASCs did not influence survival.

Home-based long-term physical endurance and inspiratory muscle training in children and adults with Fontan circulation.

Regular physical activity is highly recommended for patients with Fontan hemodynamics. Our aim was to investigate the effects of a long-term individualized home-based endurance training (IHET) on a bicycle ergometer in combination with inspiratory muscle training (IMT) in pediatric and adult patients after Fontan palliation. Additionally, factors influencing the trainability of Fontan palliated patients were analyzed. From 2018 to 2021 a single-center prospective study was performed initially including 25 Fontan palliated patients. During study period nine patients were excluded due to incompliance. A Magbike® bicycle ergometer (DKN Technology, France) was used for IHET and a POWERbreathe® Medic plus device (HaB GmbH, Germany) was utilized for the IMT. Over the study period, bike training was increased from 90 min of basic endurance training per week to additional 25 min of interval training per week. IMT consisted of 30 breaths per day for 6-7 days per week with pressure adaption over time. Patients underwent cardiopulmonary exercise testing (CPET) and body plethysmography including measurement of respiratory muscle strength at baseline and at follow-up examinations at 4, 10 and 22 months. Follow-up examinations were completed by 18/25 patients (72.0%) at 4 and 10 months and 16/25 patients (64.0%) at 22 months. Median exercise capacity slightly increased by 0.13 W/kg from baseline to last follow-up (p = 0.055, 95%CI: 0.0-0.36). However, a significant increase of oxygen pulse of 0.7 ml/beat (p = 0.006, 95%CI: 0.38-2.22) was detectable. IMT significantly improved respiratory function with an increase of inspiratory vital capacity (VCin/reference) by 4.0% (p = 0.016, 95%CI: 0.8-8). Median maximal inspiratory pressure increased by 1.2 kPa (p = 0.003, 95%CI: 0.64-3.19) and expiratory pressure by 1.5 kPa (p = 0.036, 95%CI: 0.08-2.29). No adverse events or unplanned interventions occurred during the study. Patients' subjective quality of life did not significantly change over the study period. In Fontan palliated patients, IHET in combination with IMT leads to a significant increase in oxygen pulse, inspiratory vital capacity as well as median maximal inspiratory and expiratory pressure but not to significant improvement of quality of life. Fontan patients should be encouraged to perform regular home-based exercise training.