Palliative Relief Research Articles

Interventions for palliative symptom control in COVID-19 patients.

Interventions for palliative symptom control in COVID-19 patients.

The Lancet Commission on cancer and health systems: harnessing synergies to achieve solutions

The Lancet Commission on cancer and health systems: harnessing synergies to achieve solutions

Accesso alle cure palliative e alla terapia del dolore. Considerazioni e bilanci sullo stato di attuazione della legge n. 38 del 15 marzo 2010 a 10 anni dalla sua entrata in vigore

The right of access to palliative care and pain relief is recognized and protected in the context of the essential assistance levels, in order to ensure “respect for the dignity and the autonomy of each person, the need for health, equity in access to assistance, the quality of care and its appropriateness with regard to specific needs”. The legal system has to guarantee this right providing adequate means to relieve from suffering. However, it is from the data provided by the regions, in this sector and considering the means provided by them, that emerges a picture characterized by lights and shadows.

Choriocarcinoma Induced Thyrotoxicosis in a Male Adult

Introduction: Germ cell tumors normally occur in the gonads but may be found in extragonadal sites (due to abnormal migration of germ cells during embryogenesis). Metastatic choriocarcionomas are non-seminomatous germ cell tumors which overproduce beta Human Chorionic Gonadotropin (hCG). Rarely, thyrotoxicosis can be driven by germ cell tumor-mediated hCG excess. This hormone binds to the TSH receptor with reduced potency compared to intact TSH. Paraneoplastic thyrotoxicosis, driven by extremely high levels of hCG, is a rare condition which can be associated with choriocarcinomas. Case Presentation: We present a case of 29-year-old man with metastatic extragonadal choriocarcinoma under active treatment with oxaliplatin, paclitaxel, gemcitabine (2 cycles completed), right upper lobe resection and whole brain radiation. He was admitted for small bowel obstruction and persistent tachycardia which prompted evaluation of thyroid function. His initial labs were remarkable for TSH <0.01 mclU/mL (0.27-4.20 mclU/mL), FT4 of 6.38 ng/dL (0.93-1.70 ng/dL), total T3 261 ng/dL (75-170 ng/dL), and beta hCG 578,259 mlU/ML (0-2 mlU/ML). His most recent round of chemotherapy was 7 days prior to admission. He was started on atenolol and methimazole but his FT4 rapidly declined, hence methimazole was stopped after one dose of 40 mg. Sevenfold decrease in FT4 to 0.93 ng/dL correlated with fivefold decrease in beta hCG levels to 98,921 mlU/ML. A week later his FT4 increased to 2.42 ng/dL along with increase of beta hCG to 448,116 mlU/ML. At this point he developed multiple complications due to progressive metastatic disease including acute urinary retention, shortness of breath, abdominal pain, tachycardia, acute anemia and thrombocytopenia, anxiety and was started on methimazole as part of palliative treatment for symptom relief. Unfortunately, he passed away three weeks after initial presentation of thyrotoxicosis due to widespread disease. Discussion: Choriocarcinoma is very rare and aggressive germ cell tumor especially in males. Unfortunately, the widespread nature of choriocarcinomas at the time of diagnosis is a major main reason for poor prognosis. Clinical manifestations of thyrotoxicosis associated with choriocarcinoma such as tachycardia, anxiety, tachypnea are variable and often can overlap with constitutive symptoms in widespread malignancy. Even if a definitive cure of choriocarcinoma is not attainable, recognizing an associated paraneoplastic thyrotoxicosis can provide an important pathway to provide palliative symptom relief.

Care for Older People with Dementia During COVID-19 Pandemic.

Older people living with dementia, who are likely frail with multiple comorbidities, appear particularly vulnerable to COVID-19. Care for older people with comorbid dementia and COVID-19 is a challenge to health care professionals due to their complex needs. COVID-19 is a respiratory disease which typically presents with respiratory symptoms; however, in older people with dementia, it may present atypically with delirium. Delirium may precede respiratory symptoms, and in some cases, it may be the only symptom, leading to a delay in the diagnosis. Therefore, screening for delirium should be part of the routine clinical practice for older people with dementia and suspected COVID-19 infection. Due to the complexity of care required for older people with dementia affected by COVID-19, a holistic and individualised approach that includes acute, transitional and long-term care is required. Advanced decision-making, for example, ceiling of care and resuscitation decisions, should be made early on admission to hospital. Screening for frailty with clinical frailty scale may help to aid decision-making. Palliative care and relief of suffering should be considered from the outset. Early and regular involvement of patients and their families in care plans and periodic updates regarding any changes in the clinical condition are good clinical practice. The introduction of telehealth programmes that are suitable for older people with poor cognitive function and also cover diverse cultural backgrounds are urgently required for the future support of this vulnerable group of patients.

Late Metastatic Renal Cell Carcinoma Recurrence Presenting as a Maxillary Sinus Mass 12 Years after Nephrectomy: Case Report and Literature Review

Metastasis to the sinonasal cavity is rare. Late recurrence, such as metastasis developing 10 years or more after nephrectomy, is even more rare. We present a rare case of late metastatic renal cell carcinoma (RCC) in the maxillary sinus after nephrectomy and discuss reported sinonasal metastatic RCC cases. A 64-year-old man presented with left nasal obstruction for the previous one year. He had undergone right nephrectomy to treat RCC 12 years prior. Paranasal sinus computed tomography and magnetic resolution imaging revealed a 4.6-cm-diameter mass exhibiting delayed contrast enhancement that filled the left maxillary sinus and the nasal cavity. Histologically, clear cell RCC was diagnosed. We resected the maxillary sinus tumor to resolve the nasal obstruction for palliative symptom relief. There has been no evidence of recurrence to date, 3 years postoperatively. When a patient with a history of RCC presents with a hypervascular paranasal sinus mass, metastatic RCC should be considered, despite history of nephrectomy. It is important to make an appropriate treatment plan depending on extent of metastases and location of the metastatic tumor.

COVID-19: time to rethink palliative care strategy in resource-poor settings.

COVID-19: time to rethink palliative care strategy in resource-poor settings.

Dying individuals and suffering populations: applying a population-level bioethics lens to palliative care in humanitarian contexts: before, during and after the COVID-19 pandemic

BackgroundHumanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care—a specialty focusing on supporting people with serious or terminal illness or those nearing death....

Interdisciplinary Approach to Palliative Care: A Survey of Tools and an Affordable Technique

Palliative care is a multidisciplinary approach to health care for individuals with life limiting illnesses. Its primary focus is to prevent and relive suffering from symptoms related to the illness through early identification, correct assessment and treatment of symptoms such as pain and other physical, psychosocial and spiritual problems. Researchers on palliative care have concluded that increased adaptation of tools enhances identification of patients who would benefit through palliative care and hence provide adequate care suitably. The two significant challenges are introduction of early palliative care and symptoms relief. With advances and easy access to smart phones, opportunities exist for providing improved health care to cancer patients with cost-effective and targeted care coordination. This paper presents a survey of tools designed for palliative care and a feasible framework for designing an Intelligent Multi-Agent System which provides palliative care patients with immediate and proactive medical services through monitoring and diagnosis, therapy and consultation using personal computers and Smart Phones.

Percutaneous Management of Cancer Pain.

To describe several effective imaging-guided, minimally invasive treatments to relieve cancer-associated pain in oncologic patients. Clinical applications, technical considerations, and current controversies are addressed. The great variability in tumor subtype, location, and growth rates dictate the necessity for a tailored treatment approach. While opioids and radiotherapy may provide adequate relief for some patients, alternative minimally invasive procedures may augment theses more traditional treatments or even provide superior palliative relief. Recent image-guided percutaneous techniques applied to reduce cancer-associated pain and minimize opioid dependence include neurolysis, ablation, high intensity focused ultrasound, and bone consolidation. Each technique treats cancer pain in a unique method. Minimally invasive interventional radiology techniques can provide effective and lasting pain palliation for cancer patients through both indirect and direct effects. Selection among treatments techniques should be based upon an individually tailored approach, to include consideration of all treatment modalities.

Erratum to: Ablative treatment options for locally advanced unresectable and borderline resectable pancreatic carcinoma

Background Locally advanced unresectable (nonmetastatic) and borderline resectable pancreatic carcinomas represent a therapeutic challenge. Several minimally invasive local ablative techniques are available for local treatment in these situations. Objective Which interventional techniques and application options are currently available for pancreatic carcinoma and which oncological results could be achieved so far? Material and methods An analysis of reviews and studies was carried out. The selection of literature was based on searches in PubMed and the Cochrane library. The studies analyzed were reviews, meta-analyses and original articles mainly from the period between 2013 and 2018. Single case reports were not included in this review. Results Local ablative techniques are performed with various forms of energy and are associated with specific advantages and disadvantages. They have to be individually tailored to the specific patient and situation. Noninvasive thermal ablation with high-intensity focused ultrasound (HIFU) is primarily used for palliative pain relief. Solid tumors are the main indication for thermal necrosis with microwave ablation (MWA) and radiofrequency ablation (RFA). The use of irreversible electroporation (IRE) enables a selective destruction of tumor cells and can be performed in the vicinity of sensitive structures. This technique is applied for primary tumor control and also for accentuation of tumor margins during resection. Conclusion With local ablative techniques an improvement in the quality of life and possibly the prognosis can be achieved in patients with unresectable pancreatic cancer; however, the latter aspect has to be viewed with caution due to a current lack of well-founded data.

Illness-related suffering and need for palliative care in Rohingya refugees and caregivers in Bangladesh: A cross-sectional study.

Despite recognition that palliative care is an essential component of any humanitarian response, serious illness-related suffering continues to be pervasive in these settings. There is very limited evidence about the need for palliative care and symptom relief to guide the implementation of programs to alleviate the burden of serious illness-related suffering in these settings. A basic package of essential medications and supplies can provide pain relief and palliative care; however, the practical availability of these items has not been assessed. This study aimed to describe the illness-related suffering and need for palliative care in Rohingya refugees and caregivers in Bangladesh. Between November 20 and 24, 2017, we conducted a cross-sectional study of individuals with serious health problems (n = 156, 53% male) and caregivers (n = 155, 69% female) living in Rohingya refugee camps in Bangladesh, using convenience sampling to recruit participants at the community level (i.e., going house to house to identify eligible individuals). The serious health problems, recent healthcare experiences, need for medications and medical supplies, and basic needs of participants were explored through interviews with trained Rohingya community members, using an interview guide that had been piloted with Rohingya individuals to ensure it reflected the specificities of their refugee experience and culture. The most common diagnoses were significant physical disabilities (n = 100, 64.1%), treatment-resistant tuberculosis (TB) (n = 32, 20.5%), cancer (n = 15, 9.6%), and HIV infection (n = 3, 1.9%). Many individuals with serious health problems were experiencing significant pain (62%, n = 96), and pain treatments were largely ineffective (70%, n = 58). The average age was 44.8 years (range 2-100 years) for those with serious health problems and 34.9 years (range 8-75 years) for caregivers. Caregivers reported providing an average of 13.8 hours of care per day. Sleep difficulties (87.1%, n = 108), lack of appetite (58.1%, n = 72), and lack of pleasure in life (53.2%, n = 66) were the most commonly reported problems related to the caregiving role. The main limitations of this study were the use of convenience sampling and closed-ended interview questioning. In this study we found that many individuals with serious health problems experienced significant physical, emotional, and social suffering due to a lack of access to pain and symptom relief and other essential components of palliative care. Humanitarian responses should develop and incorporate palliative care and symptom relief strategies that address the needs of all people with serious illness-related suffering and their caregivers.

Prefectural Adequacy of Opioid Availability for Cancer Pain and Its Determinants in Japan: A Preliminary Study.

Introduction: Opioid analgesics are the mainstay of cancer pain management. The annual opioid consumption globally indicates adequate opioid availability and the quality of palliative care. We investigated the current situation regarding the adequacy of opioid availability in individual prefectures in Japan and explored the determinants of adequacy. Methods: We analyzed nationwide databases open to public inspection depicting the current Japanese healthcare situation. Opioid consumption for cancer pain was estimated from oxycodone and morphine data in the nationwide database. On the basis of the World Health Organization recommendations, we calculated adequacy based on the annual cancer deaths in each prefecture in 2013 and 2015. We investigated the associations between adequacy and either outpatient medical expenditure for hypertension and diabetes as a proxy of primary care practice or ratios of these risk holders in community. Outpatient medical expenditures for musculoskeletal disorders and neoplasms were also investigated. Results: The nationwide adequacy of opioid availability was approximately 75%. The largest gaps in adequacy between prefectures were more than 65%. The adequacy correlated with expenditure but not local volumes of hypertension and diabetes in both years. The other two expenditures did not relate to opioid availability. Conclusions: Although precise data are required, our preliminary findings indicate that primary care practice is the key regulator of adequate opioid availability. Opioid adequacy in Japan is thus delayed in matching the global standard, and gaps in opioid adequacy among prefectures should be bridged rapidly to expand universal access to effective palliative care and cancer pain relief.

Stem Cell Aging and Regenerative Medicine.

Stem cells are a promising source for regenerative medicine to cure a plethora of diseases that are currently treated based on either palliative or symptomatic relief or by preventing their onset and progression. Aging-associated degenerative changes in stem cells, stem cell niches, and signaling pathways bring a step by step decline in the regenerative and functional potential of tissues. Clinical studies and experiments on model organisms have pointed out checkpoints that aging will inevitably impose on stem cell aiming for transplantation and hence questions are raised about the age of the donor. In the following discourse, we review the fundamental molecular pathways that are implicated in stem cell aging and the current progress in tissue engineering and transplantation of each type of stem cells in regenerative medicine. We further focus on the consequences of stem cell aging on their clinical uses and the development of novel strategies to bypass those pitfalls and improve tissue replenishment.

Percutaneous transhepatic biliary stent placement in the palliative management of malignant obstructive jaundice: initial experience in a tertiary center in Ghana.

Introductionone of the mainstays of management of malignant biliary obstruction is the decompression of the biliary system and its associated obstructive symptoms. Non-surgical palliative treatment such as percutaneous transhepatic biliary stenting is desirable in many selected patients. However, this service is often not available in many resource-limited countries. We share our initial experience of percutaneous transhepatic biliary stenting for the management of malignant biliary obstruction in our first set of patients with surgically non resectable malignant biliary obstruction in Ghana.Methodspercutaneous transhepatic biliary stenting was performed on the first 23 consecutive patients at the Korle Bu Teaching Hospital. The procedure served as the first palliation for malignant obstruction through interventional radiology. Medical records as well as serum levels of total bilirubin (TBil), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were used to assess the efficiency of the intervention. Microsoft Excel 2010 was used to analysis the data.Resultsmost patients had resolution of jaundice with marked improvement in liver function and resolution of the itching associated with obstructive jaundice. During the follow-up of cases, one major complication of hemoperitoneum occurred requiring laparotomy. No other major complications such as bile leakage or death occurred. Four (4) patients had sepsis, which was managed.Conclusionthe introduction of the intervention in Ghana has proven to valuable for palliative drainage and relief of obstructive symptoms, hence contributing to better patient management. It is relatively safe with minor complications among Ghanaians with non-resectable obstructive symptoms.

Ablative treatment options for locally advanced unresectable and borderline resectable pancreatic carcinoma

Locally advanced unresectable (nonmetastatic) and borderline resectable pancreatic carcinomas represent atherapeutic challenge. Several minimally invasive local ablative techniques are available for local treatment in these situations. Which interventional techniques and application options are currently available for pancreatic carcinoma and which oncological results could be achieved so far? An analysis of reviews and studies was carried out. The selection of literature was based on searches in PubMed and the Cochrane library. The studies analyzed were reviews, meta-analyses and original articles mainly from the period between 2013 and 2018. Single case reports were not included in this review. Local ablative techniques are performed with various forms of energy and are associated with specific advantages and disadvantages. They have to be individually tailored to the specific patient and situation. Noninvasive thermal ablation with high-intensity focused ultrasound (HIFU) is primarily used for palliative pain relief. Solid tumors are the main indication for thermal necrosis with microwave ablation (MWA) and radiofrequency ablation (RFA). The use of irreversible electroporation (IRE) enables aselective destruction of tumor cells and can be performed in the vicinity of sensitive structures. This technique is applied for primary tumor control and also for accentuation of tumor margins during resection. With local ablative techniques an improvement in the quality of life and possibly the prognosis can be achieved in patients with unresectable pancreatic cancer; however, the latter aspect has to be viewed with caution due to acurrent lack of well-founded data.

PDTM-34. RADIOSENSITIZATION BY BRD4 INHIBITION IN DIFFUSE INTRINSIC PONTINE GLIOMA

Abstract Diffuse intrinsic pontine glioma (DIPG), the most frequent brainstem tumor in pediatrics, is one of the devastating childhood cancers, and virtually all patients die within two years after diagnosis. Since these tumors occur in the brainstem which is vital area, there are no surgical options for providing relief to patients, and conventional chemotherapy as well as radiation therapy provides palliative relief at best. DIPG shows increased H3 K27 acetylation (H3K27ac), which binds to BET bromodomain protein 4 (BRD4) and they are strongly associated with active transcription. Here we tested the hypothesis that BRD4 inhibition by JQ1 enhances radiation-induced DNA damage, making it a potential radiosensitizer in the treatment of DIPG. We evaluated the effects of JQ1 on genes expression using RNA sequence. Radiation-induced DNA double-strand break (DSB) repair was analyzed by immunocytochemistry and western blotting of DSB markers γH2AX and 53BP1, and DSB repair markers pRad50 and Rad51. Clonogenic survival assay was used to determine the effect of JQ1 on radiation response of DIPG cells. In vivo response to radiation monotherapy and combination therapy of RT and JQ1 were evaluated in patient-derived DIPG xenografts. JQ1 significantly reduced the expression of DNA DSB repair genes in DIPG cells. JQ1 sustained high levels of γH2AX and 53BP1 and reduced the levels of pRad50 and Rad51 in irradiated DIPG cells. JQ1 reduced clonogenic survival and enhanced radiation effect in DIPG cells. In vivo studies revealed increased survival of animals treated with combination therapy of RT and JQ1 in compared to either monotherapy. Together, these results highlight JQ1 as a potential radiosensitizer and provide a rationale for developing combination therapy with radiation in the treatment of DIPG.

Bisphosphonates—much more than only drugs for bone diseases

α,α-Bisphosphonates (BPs) are well established in the treatment of bone diseases such as osteoporosis and Paget's disease. Their successful application originates from their high affinity to hydroxyapatite. While the initially appreciated features of BPs are already beneficial to many patients, recent developments have further expanded their pleiotropic applications. This review describes the background of the interactions of BPs with bone cells that form the basis of the classical treatment.A better understanding of the mechanism behind their interactions allows for the parallel application of BPs against bone cancer and metastases followed by palliative pain relief. Targeted therapy with bone-seeking BPs coupled with a diagnostic agent in one particle resulted in theranostics which is also described here. For example, in such a system, BP moieties are bound to contrast agents used in magnetic resonance imaging or radionuclides used in positron emission tomography. In addition, another example of the pleiotropic function of BPs which involves targeting the imaging agents to bone tissues accompanied by pain reduction is presented in this work.

Palliative care and symptom relief for people affected by multidrug-resistant tuberculosis.

The World Health Organization (WHO) defines palliative care as the prevention and relief of the physical, psychological, social and spiritual suffering of adults and children with life-threatening illnesses and psycho-social support for their families. Palliative care and symptom relief (PCSR) also addresses suffering in nonlife-threatening situations such as after cure. PCSR should never be considered a substitute for tuberculosis (TB) prevention and treatment, but should be accessible by everyone in need. PCSR can reduce suffering and improve quality of life of patients with end-stage chronic illnesses while reducing costs for health care systems and providing financial risk protection for patients' families. It also may help enable patients to adhere to long and noxious treatments and thereby reduce mortality and help protect public health. Basic PCSR can be taught easily to TB specialists as well as primary care clinicians and delivered in hospitals, clinics or patients' homes combined with infection control. For these reasons, integration of PCSR into multidrug-resistant (MDR) and extensively drug-resistant TB (XDR-TB) treatment programs is medically and morally imperative. We propose an essential package of PCSR for people with M/XDR-TB that includes a set of safe, effective and inexpensive medicines and equipment, social supports for patients and caregivers living in extreme poverty, and necessary human resources. The package aligns with WHO guidance on programmatic management of drug-resistant (DR) TB and should be universally accessible by people affected by M/XDR-TB. We also describe the ethical practice of PCSR for people with M/XDR-TB and identify needed areas of research in PCSR for people with M/XDR-TB.

Integrating palliative care and symptom relief into responses to humanitarian crises.

Integrating palliative care and symptom relief into responses to humanitarian crises.