Palliative Relief Of Symptoms Research Articles

End-of-life Decisions

End-of-life decisions in neurology have repeatedly given occasion for controversies. Often these are based on lack of knowledge of the juridical and ethical framework conditions. This review describes the juridical-ethical basis for the implementation and continuation, and for withholding and withdrawal of life-sustaining measures, in particular, the significance of medical indication and patient's will. The different forms of assisted dying ("Sterbehilfe"), namely homicide by request, assisted suicide, palliative symptom relief and treatment withdrawal are characterized. The "Principles of the German Medical Association" in end-of-life situations are illustrated. Specific features of neurological treatment scenarios are discussed such as the preclinical and clinical emergency and acute situation, the decompensation of stable chronic severe brain injury situations, and chronically progressive neurodegenerative diseases. In the latter situations, an early "Advance Care Planning" could contribute to improved end-of-life decision-making.

P-030 Cryoablation in the Cervical Spine

PurposeTo demonstrate the feasibility in treating primary and metastatic lesions to the cervical spine and paraspinal soft tissues using CT-guided cryoablation. To share techniques of avoiding/displacing critical structures and the...

Angio-Seal closure of an iatrogenic right ventricular perforation

Vascular closure devices are commonly used following arteriotomy as they improve patient comfort, provide rapid hemostasis, and shorten discharge time following coronary angiography [3]. The off-label use of these devices is relatively uncommon and limited to other arterial injuries [1, 4]. Pericardiocentesis is frequently performed for diagnosis and therapeutic management of hemodynamically significant pericardial effusions. Although relatively safe, complication rates between 1.0 and 4.8 % have been reported—including pneumothorax, ventricular puncture and liver laceration [5]. Ventricular perforation, while infrequent (incidence rate between 0.4 and 1.4 %) is the most serious complication, which is typically managed surgically. Herein, we report a case of an iatrogenic placement of a pigtail catheter in the right ventricle (RV), which was successfully closed via Angio-Seal collagenbased arterial closure device. A 75-year-old male with past medical history of recurrent large B cell lymphoma was referred for dyspnea and a large pericardial effusion. On assessment, the patient was tachycardic with an elevated jugular venous pressure. Chest X-ray demonstrated a loculated right-sided pleural effusion and an enlarged cardiac silhouette. An echocardiogram demonstrated a large circumferential pericardial effusion (Fig. 1a). Pericardiocentesis from a parasternal approach with placement of an eight French pigtail catheter was performed for palliative symptom relief. A large volume (greater than 1 L) of frank blood raised suspicion of right ventricular perforation. A repeat echocardiogram using Definity contrast confirmed the position of the pigtail catheter within the RV (Fig. 1b, Supplemental Video 1). A computed tomography study of the chest confirmed RV catheter placement and raised suspicion of tumor encasing the myocardium rather than pericardial effusion (Fig. 1c, d). Cardiac surgery was consulted but given the patients prognosis surgical intervention was declined. Accordingly, in conjunction with the patient a decision was made to attempt percutaneous closure. Contrast injection through the venous catheter reconfirmed the RV placement (Supplemental Video 2). A guide wire was introduced into the RV and the pigtail catheter was withdrawn. Pulsatile bleeding was observed from the catheter tract. An 8Fr Angio-Seal closure device was then introduced into the RV and deployed and anchored in the usual fashion. The collagen plug was depressed and tension maintained for several minutes (Supplemental Video 3). Successful closure was confirmed by lack of bleeding from the entry site and echocardiography demonstrating no fluid accumulation. A repeat CT scan the following day identified the collagen plug at the pigtail insertion site (Fig. 1e). The patient passed away several days later. Autopsy revealed no pericardial fluid and presence of tumor A. Pourdjabbar and B. Hibbert have contributed equally.

Surgical Resection of Malignant Melanoma Metastatic to the Pancreas: Case Series and Review of Literature

Malignant melanoma only rarely metastasizes to the pancreas. As such, there is limited medical literature on the clinical course and outcomes for patients who have undergone surgical management of these tumors. The aim of our study was to review our experience with the surgical resection of melanoma metastatic to the pancreas. The records of five patients (four females, one male) with surgically resected melanoma metastatic to the pancreas were retrospectively reviewed. Tumor characteristics, patient presentation, operative details, and follow-up data were evaluated. The primary site of melanoma was known in three cases and unknown in two cases. Four patients were symptomatic at presentation, including abdominal pain (n = 3), jaundice (n = 2), abdominal distension (n = 1), bleeding metastases (n = 1), and fatigue (n = 1). In one patient, the metastasis was an incidental discovery. Surgical resection was accomplished by pylorus-preserving pancreaticoduodenectomy in four patients and distal pancreatectomy in one patient. Single-site resection was done in two patients while the other three underwent synchronous multiple-site resections. Complications developed post-operatively in three patients. Two patients had progression of disease in the form of new metastatic lesions and received subsequent chemotherapy. The median survival was 11.4 months (range, 3-26 months). Aggressive surgical management of pancreatic metastases provides palliative relief of symptoms and may be considered in appropriately selected candidates.

Bronchial stents

Bronchial stents are mostly used as a Palliative relief of symptoms often caused by airway obstruction, It is also used for sealing of stump fistulas after pneumonectomy and dehiscence after bronchoplastic operations. Advances in airway prosthetics have provided a variety of silicone stents, expandable metal stents, and pneumatic dilators, enabling the correction of increasingly complex anatomical problems. Several series have been published describing the application and results of these techniques. This manuscript reviews the historical development of stents, types, indication, outcome, and complications. Alternative therapies for tracheobronchial stenting were also reviewed<b> <br></b>

Secondary carcinomatous infiltration of the penis: palliation with radiotherapy

Secondary carcinomatous involvement of the penis is surprisingly uncommon considering its proximity to the site of many common primary malignancies. Management of this unpleasant condition is difficult and should be primarily aimed at palliative relief of symptoms. Four cases are presented, two with primary prostatic adenocarcinoma, one rectal carcinoma and one carcinoma of the caecum. Three of these patients, on developing penile involvement, were subjected to a single course of radiotherapy. This resulted in marked relief of pain and reduction in tumour bulk allowing an improvement in micturition, where obstructive symptoms were present. Due to the small number of cases available treatment cannot be prospectively evaluated. A logical palliative treatment for metastatic penile disease is suggested.

Cryosurgery for Malignant Endobronchial Tumors: Analysis of Outcome

More than 80% of patients with lung cancer are unsuitable for curative surgical treatment. Palliative relief of symptoms, often caused by airway obstruction, is very important. Endobronchial cryosurgery is used for destruction of intraluminal tumors. This study analyzes the effects of cryosurgery on patients with obstructive endobronchial carcinoma.Retrospective analysis of data extracted from a prospective computerized database.Tertiary referral thoracic surgical center.Data of the 172 patients who underwent at least two sessions of endobronchial cryosurgery (group A) were compared with 157 patients who underwent one session of cryosurgery (group B) for malignant primary or metastatic obstructive lung carcinoma over a 5-year period.Endobronchial cryosurgery is performed under general anesthesia. A nitrous oxide cryoprobe is inserted through a rigid bronchoscope. The probe achieves a temperature of - 70 degrees C at its tip and is applied to the tumor for two 3-min periods. Statistical analysis assessed the effects of cryosurgery on symptoms, lung function, Karnofsky performance score, and survival.Symptoms of dyspnea, cough, and hemoptysis were significantly reduced in both groups after cryosurgery (p < 0.001), although group A benefited more than group B. Lung function test results improved significantly in group A. The mean Karnofsky performance score (+/- SD) increased from 67 +/- 9 to 74 +/- 10 (group A) and from 67 +/- 10 to 73 +/- 11 (group B). The mean survival was 15 months (median, 11 months) for group A and 8.3 months (median, 6 months) for group B (p = 0.006). Univariate regression analysis showed that no particular patient or tumor characteristic was associated with reduction of symptoms. Patients who had cryosurgery and external beam radiotherapy showed longer survival (p < 0.01). Females and patients with stage IIIa and IIIb tumors achieved significantly improved Karnofsky scores (p < 0.02). Female sex was also a factor for increase in FEV at 1 min (p = 0.003) and FVC (p < 0.001).Cryosurgery is a safe method for palliation of endobronchial malignancies causing airway obstruction. Statistical analysis showed improvement of dyspnea, cough, and hemoptysis. Cryosurgery can be considered in patients with inoperable obstructive endobronchial carcinoma.

Optimal treatment of Zollinger-Ellison syndrome and related conditions in elderly patients.

Zollinger-Ellison syndrome is characterised by refractory peptic ulcer disease, severe diarrhoea and gastric acid hypersecretion associated with an islet-cell tumour of the pancreas (gastrinoma). The true incidence and prevalence of this rare disease is unknown; in the US, the frequency is one per one million people and the age at presentation varies from 7 to 90 years. Zollinger-Ellison syndrome is sporadic in 62-80% of cases and in 20-38% of cases is associated with multiple endocrine neoplasia type 1 (MEN 1). The diagnosis of Zollinger-Ellison syndrome is certain when the plasma gastrin is >1000 pg/mL and the basal acid output is >15 mEq/h in patients with an intact stomach, >5 mEq/h in gastrectomised patients, or when this hypergastrinemia is associated with a pH <2. The treatment is based on control of gastric acid hypersecretion and of the malignant tumour and its possible metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered in the elderly at high dosages without drug-related adverse effects. As an initial therapy, daily dosages of omeprazole 80-100 mg or pantoprazole 40-160 mg are employed. In long-term treatment the doses can be greatly reduced once effective control of the gastric output has been established. Intravenous proton pump inhibitors may be administered when patients cannot take oral therapy, particularly in acute conditions. All sporadic localised gastrinomas should be excised if possible. When liver metastases are also present, their debulking may improve symptoms and survival, and facilitate medical treatment. There is some controversy as to the surgical approach for gastrinomas associated with MEN 1. Somatostatin analogues can be useful in reducing gastric acid hypersecretion, serum gastrin and gastric enterochromaffin-like (ECL) cells and can thus contribute to treating the disease more effectively. Their antiproliferative effect can be used in treating liver metastases. Chemotherapy is not the therapy of choice in patients with gastrinomas and is indicated only in those with malignant progressive disease; interferon alpha, embolisation and chemoembolisation are not advisable for the elderly. The treatment of elderly Zollinger-Ellison syndrome patients, similarly to all elderly oncological patients, should be based on the use of comprehensive geriatric assessment. This will enable the clinician to define the functional status of the elderly person, to decide whether the patient can tolerate surgery and/or the stress of antineoplastic therapy, and finally, to determine whether this patient can tolerate an aggressive treatment for Zollinger-Ellison syndrome or whether the only possible choice is palliative relief of symptoms.

Steroid Receptors in Breast Cancer

Since the report by Beatson1in 1896 of human mammary tumor regression occurring after bilateral oophorectomy, much interest has developed in the hormonal dependence of these tumors. Subsequently, it has been shown that a wide variety of both ablative, eg, adrenalectomy and hypophysectomy, and additive, eg, estrogen, progestin, androgen, and glucocorticoid, endocrine therapies are effective in causing regressions of tumors in certain patients with breast cancer. The importance of hormonal therapy lies in the fact that patients who respond to such therapy not only have palliative relief of symptoms, but they also have prolonged survival when compared with patients who do not respond. Unfortunately, only a third of unselected patients with breast cancer can be expected to have an objective response to endocrine manipulation. During the years, several clinical features have been empirically derived as useful indices to predict which patients would respond more often to endocrine therapy. These

Steroid Receptors in Breast Cancer

Since the report by Beatson1in 1896 of human mammary tumor regression occurring after bilateral oophorectomy, much interest has developed in the hormonal dependence of these tumors. Subsequently, it has been shown that a wide variety of both ablative, eg, adrenalectomy and hypophysectomy, and additive, eg, estrogen, progestin, androgen, and glucocorticoid, endocrine therapies are effective in causing regressions of tumors in certain patients with breast cancer. The importance of hormonal therapy lies in the fact that patients who respond to such therapy not only have palliative relief of symptoms, but they also have prolonged survival when compared with patients who do not respond. Unfortunately, only a third of unselected patients with breast cancer can be expected to have an objective response to endocrine manipulation. During the years, several clinical features have been empirically derived as useful indices to predict which patients would respond more often to endocrine therapy. These