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Bernacki R, Periyakoil VS. Best Practices in Caring for Seriously Ill Patients. Ann Intern Med 2024. [PMID: 38976884 DOI: 10.7326/aitc202407160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024] Open
Abstract
Palliative care (PC) is the art and science of providing goal-concordant care, skillfully managing complex and refractory pain and nonpain symptoms, mitigating suffering, and augmenting quality of life for seriously ill patients throughout the course of the illness trajectory. The primary team should provide generalist PC for all seriously ill patients and know when to refer patients to specialist PC. Specialty-level PC services should be reserved for complex problems beyond the scope of primary PC. This article reviews principles and best practices to support patient-centered PC.
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Affiliation(s)
- Rachelle Bernacki
- Harvard Medical School and Dana-Farber Cancer Institute, Boston, Massachusetts (R.B.)
| | - Vyjeyanthi S Periyakoil
- Stanford University School of Medicine, Stanford, California, and VA Palo Alto Health Care System, Palo Alto, California (V.S.P.)
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2
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Chou CZ, Everett EA, McFarlin J, Ramanathan U. End-of-Life and Hospice Care in Neurologic Diseases. Semin Neurol 2024. [PMID: 38917863 DOI: 10.1055/s-0044-1787809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support. Neurologists caring for patients with advanced neurologic disease often identify changes in disease trajectory, functional status, or goals of care that prompt discussions of advance care planning and hospice. Patients nearing end-of-life may develop symptoms such as dyspnea, secretions, delirium, pain, and seizures. Neurologists may be the primary clinicians managing these symptoms, particularly in the hospitalized patient, though they may also lend their expertise to non-neurologists about expected disease trajectories and symptoms in advanced neurologic disease. This article aims to help neurologists guide patients and caregivers through the end-of-life process by focusing on general knowledge that can be applied across diseases as well as specific considerations in severe stroke and traumatic brain injury, amyotrophic lateral sclerosis, Parkinson's disease, and dementia.
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Affiliation(s)
- Claudia Z Chou
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, Minnesota
| | - Elyse A Everett
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
| | - Jessica McFarlin
- Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Usha Ramanathan
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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3
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Ishida K, Katayama Y, Kitamura T, Hirose T, Ojima M, Nakao S, Tachino J, Kiguchi T, Kiyohara K, Oda J, Ohnishi M. Impact of pre-existing medical conditions on mortality in geriatric trauma: a nationwide study in Japan. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02570-3. [PMID: 38888791 DOI: 10.1007/s00068-024-02570-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 05/30/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE To investigate the relationship between pre-existing medical conditions and outcomes in elderly trauma patients in Japan. METHODS This multicenter observational study utilized data from the Japan Trauma Data Bank (JTDB) from 2019 to 2020. The primary outcome was in-hospital mortality. Factors associated with in-hospital mortality were identified using multivariate logistic regression analysis, from which adjusted odds ratios (AOR) and 95% confidence intervals (CI) were determined. RESULTS Of the participants during the study period, 19,598 patients were included in the analysis. Among the pre-existing medical conditions, moderate or severe liver disease showed the strongest positive association with in-hospital mortality (AOR: 7.087, 95% CI: 3.194-15.722), followed by multiple malignancies (AOR: 3.490, 95% CI: 1.046-11.641), congestive heart failure (AOR: 2.572, 95% CI: 1.920-3.445), and moderate or severe renal disease (AOR: 2.256, 95% CI: 1.584-3.215). CONCLUSION Data from JTDB suggests that pre-existing conditions like moderate or severe liver disease, congestive heart failure, and moderate or severe renal disease in elderly trauma patients are positively correlated with in-hospital mortality.
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Affiliation(s)
- Kenichiro Ishida
- Department of Acute Medicine and Critical Care Medical Center, NHO Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan.
| | - Yusuke Katayama
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuhisa Kitamura
- Environmental Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masahiro Ojima
- Department of Acute Medicine and Critical Care Medical Center, NHO Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan
| | - Shunichiro Nakao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jotaro Tachino
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takeyuki Kiguchi
- Department of Emergency and Critical Care, Osaka General Medical Center, Osaka, Japan
- Kyoto University Health Service, Kyoto, Japan
| | - Kosuke Kiyohara
- Department of Food Science, Faculty of Home Economics, Otsuma Women's University, Tokyo, Japan
| | - Jun Oda
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Mitsuo Ohnishi
- Department of Acute Medicine and Critical Care Medical Center, NHO Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, Japan
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4
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van Zyl C, Storms AD, van Deen W, Cardenas V, Ellis R, Flores A, Donovan J, Chu L, Patel T, Enguidanos S. A Pilot Study of a Palliative Care Service Embedded in a Hepatology Clinic at a Large Public Hospital. J Palliat Med 2023; 26:776-783. [PMID: 36577037 PMCID: PMC10398730 DOI: 10.1089/jpm.2022.0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 12/29/2022] Open
Abstract
Background: End-stage liver disease (ESLD) patients carry heavy symptom burdens and risk receiving aggressive and sometimes unwanted care at end of life. Palliative care (PC), which aims to alleviate symptoms and facilitate goal-concordant care in serious illness, may offer substantial benefits for ESLD patients but is not widely provided. Objectives: To assess the impact of PC integrated within hepatology (PCIH) services on health care utilization, advance care planning (ACP), and hospice enrollment. Design: We compared patients who received PCIH (n = 55) to a retrospective cohort (n = 57) receiving usual care in an outpatient hepatology clinic. Setting/Subjects: From June 2016 to November 2017, we enrolled patients receiving care in a U.S. public hospital clinic who met the following inclusion criteria: (1) ESLD with a Model for End-Stage Liver Disease score ≥20, (2) hepatology approval for PC referral, and (3) at least one advanced complication of ESLD. Measurements: We assessed patient demographics, clinical information, health care insurance status, health care utilization, completion of psychosocial assessments, and ACP using two-sided Fisher's exact test and Mann-Whitney U tests. Results: Patients receiving PCIH more frequently had goals of care discussions (87.3% vs. 21.2% p ≤ 0.01), completed ACP documentation (56.4% vs. 7.0%, p ≤ 0.01), psychosocial assessments (98.2% vs. 35.1%, p ≤ 0.01), and hospice enrollment (25.5% vs. 7.0%, p = 0.01). Patients receiving PCIH who were hospitalized also had fewer mean hospitalization days (13 vs. 19.7 days, p ≤ 0.01). Conclusions: Embedding PC services in a hepatology clinic is a promising strategy to improve care for ESLD patients in public hospitals.
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Affiliation(s)
- Carin van Zyl
- Department of Medicine, Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Aaron D. Storms
- Department of Medicine, Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Welmoed van Deen
- Gehr Family Center for Health Systems Science, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Erasmus School of Health Policy and Management, Health Technology Assessment Section, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Valeria Cardenas
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Robin Ellis
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - Alicia Flores
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
| | - John Donovan
- Department of Medicine, Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
- Department of Medicine, Division of Gastrointestinal and Liver Diseases, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Lily Chu
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tanu Patel
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
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5
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Peters PN, Havrilesky LJ, Davidson BA. Guidelines for goals of care discussions in patients with gynecologic cancer. Gynecol Oncol 2023; 174:247-252. [PMID: 37243995 DOI: 10.1016/j.ygyno.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 05/29/2023]
Abstract
This article represents a distillation of literature to provide guidance for goals of care discussions with patients who have gynecologic malignancies. As clinicians who provide surgical care, chemotherapy, and targeted therapeutics, gynecologic oncology clinicians are uniquely positioned to form longitudinal relationships with patients that can enable patient-centered decision making. In this review, we describe optimal timing, components, and best practices for goals of care discussions in gynecologic oncology.
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Affiliation(s)
- Pamela N Peters
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America.
| | - Laura J Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America
| | - Brittany A Davidson
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Duke University Health System, Durham, NC 27710, United States of America
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6
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Brown C, Aksan N, Muir AJ. Consider hospice in end-stage liver disease prognostic scale to open discussions regarding six-month mortality. JGH Open 2023; 7:278-285. [PMID: 37125249 PMCID: PMC10134759 DOI: 10.1002/jgh3.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/29/2023] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Abstract
Background and Aim Hospice is underutilized in the management of patients with end-stage liver disease and may improve the patient experience at the end of life. This study aims to create a novel prognostic scale to accurately predict 6-month mortality to more comprehensively facilitate hospice referral. Methods Sociodemographic, clinical, and laboratory variables associated with mortality from the United Network for Organ Sharing database were tested in univariate analysis followed by multivariate analyses with four predictor groups: Demographics, Diagnoses, Complexities, and Laboratory studies to develop the hospice in end-stage liver disease prognostic scale (HELP) scale (70% sample, N = 13 516) followed with replication in a 30% (N = 5792) internal validation sample. Results Only the predictor groups of Complexities and Laboratory studies met the c-statistic threshold of 0.70 for inclusion in the multivariate analyses. Backward elimination in the final logistic regression and validated weighted transformation procedure resulted in: HELP scale = (functional status × 11) + (ascites × 3) + (SBP × 3) + (HE × 4) + (dialysis × 5) + (TIPS × -3) + (albumin × -3) + (MELD-Na ≥ 21 × 20). HELP scale had a strong predictive value for six-month mortality with Area under the Receiver Operating Curve (AUROC) 0.816 and replicated in the validation sample. Conclusion HELP scale is a novel prognostic score utilizing the strength of model of end-stage liver disease-sodium (MELD-Na), along with clinical factors, for a more nuanced assessment of six-month mortality. This scale can provide an individualized approach in opening discussions of hospice referral and may be better accepted by patients and providers given its contextualization of important clinical factors.
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Affiliation(s)
- Cristal Brown
- Dell Medical SchoolUniversity of Texas at AustinAustinTexasUSA
| | - Nazan Aksan
- Dell Medical SchoolUniversity of Texas at AustinAustinTexasUSA
| | - Andrew Joseph Muir
- Duke University School of MedicineDuke Clinical Research InstituteDurhamNorth CarolinaUSA
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Dempsey A, Mulder J. Quality Versus Quantity of Life: Beyond the Dichotomy. Palliat Med Rep 2023; 4:17-23. [PMID: 36743341 PMCID: PMC9892925 DOI: 10.1089/pmr.2022.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/20/2023] Open
Abstract
A restrictive and dichotomous question has become the primary approach in many goals of care discussions. Is the primary goal of care quantity of life through aggressive therapy or quality of life through comfort care and hospice? Even though many health care providers recognize that quality vs quantity of life (QvQ) is a false dichotomy, in practice QvQ underlies many goals of care discussions and can negatively impact patient care. This article offers strategies for assessing patients at the end of life, presenting a first-line conversation process that can support a range of treatment options as well as a diversity of dynamic patient values. Based on decades of experience in palliative care and a review of relevant literature, we recommend four practical questions to serve as values "vital signs," monitoring dynamic notions of quality of life and harmonizing patient values with treatment options.
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Affiliation(s)
- Ariel Dempsey
- Faculty of Theology and Religion, University of Oxford, Oxford, United Kingdom
| | - John Mulder
- Department of Family Medicine, Division of Palliative Medicine, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA; Trillium Institute, Spring Lake, Michigan, USA
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8
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Rogal SS, Hansen L, Patel A, Ufere NN, Verma M, Woodrell CD, Kanwal F. AASLD Practice Guidance: Palliative care and symptom-based management in decompensated cirrhosis. Hepatology 2022; 76:819-853. [PMID: 35103995 PMCID: PMC9942270 DOI: 10.1002/hep.32378] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Shari S. Rogal
- Departments of Medicine and Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare Center, Pittsburgh, Pennsylvania, USA
| | - Lissi Hansen
- School of Nursing, Oregon Health and Science University, Portland, Oregon, USA
| | - Arpan Patel
- Division of Digestive Diseases, David Geffen School of Medicine at University of California, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Christopher D. Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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9
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Jones KF, Abdulhay LB, Orris SR, Merlin JS, Schenker Y, Bulls HW. The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. J Pain Symptom Manage 2022; 64:89-99. [PMID: 35561937 DOI: 10.1016/j.jpainsymman.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. OBJECTIVE To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. METHODS Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). RESULTS Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. DISCUSSION The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing (K.F.J.), Boston College, Chestnut Hill, Massachusetts, USA.
| | - Lindsay Bell Abdulhay
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steve R Orris
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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10
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Clinical complications of liver disease in adults after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Risco JR, Kelly AG, Holloway RG. Prognostication in neurology. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:175-193. [PMID: 36055715 DOI: 10.1016/b978-0-323-85029-2.00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Prognosticating is central to primary palliative care in neurology. Many neurologic diseases carry a high burden of troubling symptoms, and many individuals consider health states due to neurologic disease worse than death. Many patients and families report high levels of need for information at all disease stages, including information about prognosis. There are many barriers to communicating prognosis including prognostic uncertainty, lack of training and experience, fear of destroying hope, and not enough time. Developing the right mindset, tools, and skills can improve one's ability to formulate and communicate prognosis. Prognosticating is subject to many biases which can dramatically affect the quality of patient care; it is important for providers to recognize and reduce them. Patients and surrogates often do not hear what they are told, and even when they hear correctly, they form their own opinions. With practice and self-reflection, one can improve their prognostic skills, help patients and families create honest roadmaps of the future, and deliver high-quality person-centered care.
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Affiliation(s)
- Jorge R Risco
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Adam G Kelly
- Department of Neurology, University of Rochester, Rochester, NY, United States
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, NY, United States.
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12
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Abstract
Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.
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Affiliation(s)
- Farrah N Daly
- EvenBeam Neuropalliative Care, Leesburg, VA, United States.
| | - Usha Ramanathan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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13
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Portincasa P, Di Ciaula A, Wang DQ. Longer Walking Distance, More Fat, Better Survival: Prognostic Indicators of Liver Cirrhosis. JOURNAL OF GASTROINTESTINAL AND LIVER DISEASES : JGLD 2021; 30:8-12. [PMID: 33723545 PMCID: PMC8118564 DOI: 10.15403/jgld-3455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Piero Portincasa
- Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri", University of Bari "Aldo Moro" Medical School, Bari, Italy. .
| | - Agostino Di Ciaula
- Department of Biomedical Sciences and Human Oncology, Clinica Medica A. Murri, University of Bari Aldo Moro Medical School, Bari, Italy
| | - David Qh Wang
- Department of Medicine and Genetics, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, Einstein-Mount Sinai Diabetes Research Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA
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14
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Merat S. SD1000: High Sustained Viral Response Rate in 1361 Patients With Hepatitis C Genotypes 1, 2, 3, and 4 Using a Low-cost, Fixed-dose Combination Tablet of Generic Sofosbuvir and Daclatasvir: A Multicenter, Phase III Clinical Trial. Clin Infect Dis 2021; 70:2206-2212. [PMID: 31504303 DOI: 10.1093/cid/ciz628] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/09/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The combination of sofosbuvir and daclatasvir is a potent, pangenotypic regimen suitable for mass-scale hepatitis C treatment, especially in resource-limited countries where newer, expensive combinations are not available. This combination has been widely tested on genotype 4. However, Phase III trials of this combination in other genotypes have been cost prohibitive. With the introduction of generic, low-cost sofosbuvir and daclatasvir, large-scale studies in resource-limited countries are now possible. METHODS Sofosbuvir at 400 mg and daclatasvir at 60 mg were coformulated into a fixed-dose combination (FDC) tablet (Sovodak, Rojan Pharma, Tehran, Iran). Patients from 46 centers were dosed for 12 or 24 weeks with or without ribavirin, in line with existing guidelines. Responses to treatment were evaluated 12 weeks after the end of treatment (for a sustained virological response at Week 12; SVR12). RESULTS There were 1361 patients recruited. Overall, the patients were 21% female, with a mean age of 50 years; 39% were cirrhotic; 22% were treatment-experienced; 47% were genotype 1, 41% were genotype 3, and 2% were other genotypes. The genotype was not known in 10% of the patients. The intention-to-treat and per-protocol SVR12 rates were 94.7% and 98.8%, respectively. The safety profile was unremarkable, treatment was well tolerated, and compliance with the single-tablet regimen was excellent. CONCLUSIONS The treatment with FDC of sofosbuvir and daclatasvir achieved high SVR12 rates, equivalent to those seen in Phase III trials of other pangenotypic options, and has been conducted at a similar scale in a representative, real-world population at a cost of under $100 per patient, which makes this combination suitable for elimination protocols in resource-limited countries. CLINICAL TRIALS REGISTRATION NCT03200184.
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Affiliation(s)
- Shahin Merat
- Liver and Pancreatobiliary Diseases Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Shariati Hospital, Iran
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15
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Subramoney K, Orman E, Johnson AW, Kara A. The Impact of Obesity in End of Life Care in Patients With End Stage Liver Disease: An Observational Study. Am J Hosp Palliat Care 2020; 38:1177-1181. [PMID: 33280394 DOI: 10.1177/1049909120978768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Both obesity and end stage liver disease (ESLD) are increasing. Obesity's impact on hospice and palliative care in patients with ESLD is unknown. METHODS We retrospectively evaluated patients admitted to an academic, Midwestern, tertiary center between January 2016 and May 2019 with a diagnosis of ESLD. Body Mass Index and MELD Na were calculated for each patient's first admission during the study period. Patients with MELD Na scores ≥ 21 or 18-20 with additional criteria were considered potentially eligible for hospice and palliative care referrals. RESULTS Of 3863 patients admitted with ESLD, 1556 (40%) were potentially eligible for hospice and palliative care referrals. Of these, 703 (45%) were obese. Comorbidity burden was higher in obese patients (15.6% of obese patients had a Charlson Comorbidity Index ≥ 5, while 5% of non-obese patients had a comorbidity index of ≥ 5 (p < 0.001). Referral rates to hospice and palliative services in obese patients were 10.1% and 16.4% respectively. Hospice and palliative referral rates among non-obese patients were similar (10.1% and 15.5%). Among patients who died within 6 months of the first hospitalization, the mean time to referral to hospice or palliative care from index admission was longer in obese patients. CONCLUSION Obesity is common in patients hospitalized with ESLD who may be approaching the end of life. Referral rates to hospice and palliative care services are low and similar regardless of BMI and despite higher co-morbidity burdens in obese patients. Obesity may delay referrals to hospice and palliative care.
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Affiliation(s)
| | - Eric Orman
- 10668Indiana University School of Medicine, Indianapolis, IN, USA
| | - Amy W Johnson
- 10668Indiana University School of Medicine, Indianapolis, IN, USA
| | - Areeba Kara
- 10668Indiana University School of Medicine, Indianapolis, IN, USA
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Huang HK, Chen HY, Hsu YC. Comparing the Prognosis of Patient with Alcohol and Nonalcohol-Associated Cirrhosis with Bacteremia. Alcohol Alcohol 2020; 55:512-517. [DOI: 10.1093/alcalc/agaa057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
Aims
Patients with liver cirrhosis are more susceptible to bacteremia and more likely to have a poor prognosis in comparison to healthy individuals. Studies on the role of alcohol in cirrhotic patients with bacteremia are limited. Our study aimed to investigate the clinical characteristics and prognostic differences between the patients with alcohol and non-alcohol-associated cirrhosis with bacteremia.
Methods
A single-center, retrospective cohort study was conducted among adult patients who presented to the emergency department from January 2015 to December 2018. All patients diagnosed with liver cirrhosis and bacteremia were enrolled and divided into alcohol-associated and non-alcohol-associated groups according to the etiology of their cirrhosis. We compared their clinical characteristics, laboratory results, microbiological data, and infection source as well as outcome measurements between the two groups.
Results
A total of 112 cirrhotic patients with bacteremia (alcohol-associated: 67; non-alcohol-associated: 45) were eligible for this study. In comparison with the non-alcohol-associated group, patients in the alcohol-associated group had a significantly higher rate of intensive care unit transfer (41.8% vs. 22.2%, P = 0.04), septic shock occurrence (56.7% vs. 35.6%, P = 0.04) and 30-day mortality risk (37.3% vs. 15.6%, P = 0.02). Moreover, alcohol-associated cirrhosis and Model for End-Stage Liver Disease score were independent predictors of 30-day mortality in cirrhotic patients with bacteremia.
Conclusions
The etiology of liver cirrhosis influences the outcomes of patients with bacteremia as well as the severity of their cirrhosis.
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Affiliation(s)
- Hsu-Kai Huang
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No. 1, Yida Road, Jiaosu Village, Kaohsiung 82445, Taiwan
| | - Hung-Yu Chen
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No. 1, Yida Road, Jiaosu Village, Kaohsiung 82445, Taiwan
| | - Yin-Chou Hsu
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No. 1, Yida Road, Jiaosu Village, Kaohsiung 82445, Taiwan
- School of Medicine, College of Medicine, I-Shou University, No.8, Yida Road, Jiaosu Village, Kaohsiung 82445, Taiwan
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17
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Naqvi IH, Mahmood K, Talib A. Haemorrhagic versus non haemorrhagic ascites in cirrhosis: Their relationship and impact on prognosis of liver cirrhosis. Pak J Med Sci 2020; 36:603-608. [PMID: 32494241 PMCID: PMC7260907 DOI: 10.12669/pjms.36.4.2075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To evaluate the impact of haemorrhagic ascites on prognosis of patients with advance cirrhosis, this study was further aimed to assess the relationship between haemorrhagic ascites and advance cirrhosis and its effect on prognosis. Methods Eight hundred and thirty-eight patients having liver cirrhosis with ascites were analyzed retrospectively (over three years) while segregated into two groups haemorrhagic and non haemorrhagic ascites. Patient outcome variables were identified among both groups and independent predictors for survival were analyzed. Kaplan-Meier survival estimates determined survival rate comparison between groups. Results Haemorrhagic ascites was detected in (26.6%) patients. Spontaneous haemorrhagic ascites(79%) was the main cause of haemorrhagic ascites followed by hepatocellular carcinoma (14%) and iatrogenic (7.6%). Spontaneous bacterial peritonitis and acute kidney injury were statistically significant (p= 0.0001, 0.0001) among groups. Overall mortality at year three was higher (83%) in haemorrhagic ascites group. Survival among both groups (haemorrhagic versus non haemorrhagic) at one month, one year and three year was found to be significant (p= 0.000, 0.000 and 0.000). Conclusion Haemorrhagic ascites impact overall survival with more mortality in comparison to non haemorrhagic ascites. Haemorrhagic ascites was an independent predictor of survival. Haemorrhagic ascites is possibly considered another predictor of survival among advance cirrhosis.
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Affiliation(s)
- Iftikhar Haider Naqvi
- Dr. Iftikhar Haider Naqvi, FCPS. Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Khalid Mahmood
- Prof. Khalid Mahmood, FCPS, FRCP(Edin), FRCP(Glasgow). Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Abu Talib
- Prof. Abu Talib, FCPS, FRCP(Glasgow). Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Afebrile Bacteremia in Adult Emergency Department Patients with Liver Cirrhosis: Clinical Characteristics and Outcomes. Sci Rep 2020; 10:7617. [PMID: 32376846 PMCID: PMC7203181 DOI: 10.1038/s41598-020-64644-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/16/2020] [Indexed: 12/17/2022] Open
Abstract
Cirrhotic patients with bacteremia are at an increased risk of organ failure and mortality. In addition, they can develop serious infection without fever because of their impaired immune response. Our study aimed to investigate the clinical characteristics and outcomes in afebrile bacteremic patients with liver cirrhosis. A single-center, retrospective cohort study was performed on adult patients who visited the emergency department from January 2015 to December 2018. All patients with bacteremia and diagnosis of liver cirrhosis were enrolled and classified as either afebrile or febrile. In total, 104 bacteremic patients with liver cirrhosis (afebrile: 55 patients and, febrile: 49) were included in the study. Compared with the febrile group, patients in the afebrile group showed a significantly higher rate of inappropriate antibiotics administration (43.6% vs. 20.4%, p = 0.01). They were also at an increased risk of 30-day mortality (40% vs. 18.4%, p = 0.02), intensive care unit transfer (38.2% vs. 18.4%, p = 0.03) and endotracheal intubation (27.3% vs. 10.2%, p = 0.03). The afebrile state was also an independent risk factor associated with 30-day mortality in cirrhotic patients with bacteremia. Clinicians should perform a prudent evaluation in cirrhotic patients and carefully monitor for possible signs of serious infection even in the absence of fever.
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Gómez-Batiste X, Turrillas P, Tebé C, Calsina-Berna A, Amblàs-Novellas J. NECPAL tool prognostication in advanced chronic illness: a rapid review and expert consensus. BMJ Support Palliat Care 2020; 12:e10-e20. [PMID: 32241958 DOI: 10.1136/bmjspcare-2019-002126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/24/2020] [Accepted: 03/11/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop a proposal for a 2-year mortality prognostic approach for patients with advanced chronic conditions based on the palliative care need (PCN) items of the NECesidades PALiativas (NECPAL) CCOMS-ICO V.3.1 2017 tool. METHODS A phase 1 study using three components based on the NECPAL items: (1) a rapid review of systematic reviews (SRs) on prognostic factors of mortality in patients with advanced chronic diseases and PCNs; (2) a clinician and statistician experts' consensus based on the Delphi technique on the selection of mortality prognostic factors; and (3) a panel meeting to discuss the findings of components (1) and (2). RESULTS Twenty SRs were included in a rapid review, and 50% were considered of moderate quality. Despite methodological issues, nutritional and functional decline, severe and refractory dyspnoea, multimorbidity, use of resources and specific disease indicators were found to be potentially prognostic variables for mortality across four clinical groups and end-of-life (EoL) trajectories: cancer, dementia and neurologic diseases, chronic organ failure and frailty. Experts' consensus added 'needs' identified by health professionals. However, clinicians were less able to discriminate which NECPAL items were more reliable for a 'general' model. A retrospective cohort study was designed to evaluate this proposal in phase 2. CONCLUSIONS We identified several parameters with prognostic value and linked them to the tool's utility to timely identify PCNs of patients with advanced chronic conditions in all settings of care. Initial results show this is a clinical and feasible tool, that will help with clinical pragmatic decision-making and to define services.
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Affiliation(s)
- Xavier Gómez-Batiste
- The 'Qualy' Observatory/WHO Collaborating Centre for Public Health Palliative Care Programmes, Institut Catala d' Oncologia, Barcelona, Spain .,Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain
| | - Pamela Turrillas
- The 'Qualy' Observatory/WHO Collaborating Centre for Public Health Palliative Care Programmes, Institut Catala d' Oncologia, Barcelona, Spain.,Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain
| | - Cristian Tebé
- Department of Statistics, Biomedical Research Institute of Bellvitge (IDIBELL), Barcelona, Spain
| | - Agnès Calsina-Berna
- The 'Qualy' Observatory/WHO Collaborating Centre for Public Health Palliative Care Programmes, Institut Catala d' Oncologia, Barcelona, Spain.,Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain
| | - Jordi Amblàs-Novellas
- Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic - Central University of Catalonia, Vic, Barcelona, Spain
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A Comprehensive Analysis of Liver Transplantation Outcomes Among Ethnic Minorities in the United States. J Clin Gastroenterol 2020; 54:263-270. [PMID: 31169758 DOI: 10.1097/mcg.0000000000001236] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS The aim of this study was to perform a comprehensive assessment of liver transplant (LT) outcomes among US adults with a specific focus on understanding race/ethnicity-specific disparities. BACKGROUND Despite improvements in the liver allocation and LT-related care, disparities in LT outcomes persist. STUDY Using data from the 2005 to 2016 United Networks for Organ Sharing LT registry, we evaluated waitlist survival, probability of receiving LT, and post-LT survival among US adults stratified by race/ethnicity and liver disease etiology. Kaplan-Meier methods evaluated unadjusted waitlist and post-LT outcomes, and multivariate regression models evaluated adjusted waitlist and post-LT outcomes. RESULTS Among 88,542 listed for LT patients (41.3% hepatitis C virus, 25.3% alcoholic liver disease, 22.3% nonalcoholic steatohepatitis, 11.1% hepatitis C virus/alcoholic liver disease), significant race/ethnicity-specific disparities were observed. Compared with non-Hispanic whites, Hispanics had a significantly lower risk of waitlist death [hazard ratio (HR)=0.84, 95% confidence interval (CI): 0.79-0.90, P<0.001]. Compared with non-Hispanic whites, significantly lower likelihood of receiving LT was observed in African Americans (HR=0.94, 95% CI: 0.91-0.98, P<0.001), Hispanics (HR=0.70, 95% CI: 0.68-0.73, P<0.001) and Asians (HR=0.74, 95% CI: 0.69-0.80, P<0.001). Compared with non-Hispanic whites, African Americans had a significantly higher risk of 5-year post-LT death (HR=1.31, 95% CI: 1.23-1.39, P<0.001). CONCLUSION Among US adults awaiting LT, significant race/ethnicity-specific disparities in LT outcomes were observed. Despite evaluating an era after implementation of the Model for End-Stage Liver Disease, ethnic minorities continue to demonstrate a lower probability of receiving LT, and significantly higher risk of death post-LT in African Americans.
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21
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Brucato A, Ferrari A, Tiraboschi M, Zucchi A, Cogliati C, Torzillo D, Dentali F, Tavecchia L, Gessi V, Squizzato A, Moretti S, Permunian ET, Carobbio A, Pasina L, De Stefano F, Tombetti E, Cumetti D, Tognoni G, Barbui T. Three-month mortality in permanently bedridden medical non-oncologic patients. The BECLAP study (permanently BEdridden, creatinine CLearance, albumin, previous hospital admissions study). Eur J Intern Med 2020; 72:60-66. [PMID: 31757579 DOI: 10.1016/j.ejim.2019.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/18/2019] [Accepted: 10/12/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To predict the 3-months mortality in permanently bedridden medical non-oncologic inpatients. PATIENTS AND METHODS 2788 consecutive patients admitted in 5 Italian Internal Medicine units from January 2016 through January 2017 were prospectively screened; 644 oncologic patients were excluded; 2144 non-oncologic patients (1021 female) were followed-up for mortality for 6 months. Main outcome was 3-months mortality in permanently bedridden inpatients with at least 2 of: creatinine clearance <35 ml/min; albumin < 2.5 g/dl; at least 2 hospital admissions in the previous 6 months. Advanced dementia and dysphagia were also recorded. RESULTS Mean age of the 2144 patients was 73.9 (SD, 14.9) years; 374 (17%) were permanently bedridden, 435 (20%) had a creatinine clearance <35 ml/min, 217 (10%) albumin <2,5 g/dl, 112 (5%) at least 2 hospital admissions in the previous 6 months. Seventy-seven (4%) patients were permanently bedridden with at least 2 of the above mentioned items, and 48 of them died within 3 months (62%) (p < 0.001;95% CI 51-73%). Regression coefficients of the variables associated with 3-months mortality in multivariate analysis in 998 patients of unit 1 (training cohort) were used to create a simple score, which was validated in the 1146 patients of the other units (validation cohort) and performed well in predicting the 3-months mortality (https://www.ejcrim.com/beclap/). CONCLUSIONS Approximately two out of three non-oncologic medical patients permanently bedridden having 2 of the abovementioned items are dead 3 months after index admission; a simple score including bedridden status, creatinine clearance, albumin, dysphagia, age and sex may help discuss management priorities.
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Affiliation(s)
- Antonio Brucato
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi d Milano, Ospedale Fatebenefratelli, Italy; Ospedale Papa Giovanni XXIII, Bergamo, Italy.
| | - Alberto Ferrari
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Mara Tiraboschi
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi d Milano, Ospedale Fatebenefratelli, Italy
| | - Alberto Zucchi
- Epidemiology Unit, Health Protection Agency, Bergamo, Italy
| | - Chiara Cogliati
- Internal Medicine Department, L. Sacco Hospital, ASST fbf-sacco, Milan, Italy
| | - Daniela Torzillo
- Internal Medicine Department, L. Sacco Hospital, ASST fbf-sacco, Milan, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Luca Tavecchia
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Vera Gessi
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Sara Moretti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Luca Pasina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fabio De Stefano
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi d Milano, Ospedale Fatebenefratelli, Italy
| | | | - Davide Cumetti
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi d Milano, Ospedale Fatebenefratelli, Italy
| | - Gianni Tognoni
- Dipartimento di Anestesia-Rianimazione e Emergenza Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy.
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Koola JD, Ho S, Chen G, Perkins AM, Cao A, Davis SE, Matheny ME. Development of a national Department of Veterans Affairs mortality risk prediction model among patients with cirrhosis. BMJ Open Gastroenterol 2019; 6:e000342. [PMID: 31875140 PMCID: PMC6904155 DOI: 10.1136/bmjgast-2019-000342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/16/2019] [Accepted: 10/30/2019] [Indexed: 12/20/2022] Open
Abstract
Objective Cirrhotic patients are at high hospitalisation risk with subsequent high mortality. Current risk prediction models have varied performances with methodological room for improvement. We used current analytical techniques using automatically extractable variables from the electronic health record (EHR) to develop and validate a posthospitalisation mortality risk score for cirrhotic patients and compared performance with the model for end-stage liver disease (MELD), model for end-stage liver disease with sodium (MELD-Na), and the CLIF Consortium Acute Decompensation (CLIF-C AD) models. Design We analysed a retrospective cohort of 73 976 patients comprising 247 650 hospitalisations between 2006 and 2013 at any of 123 Department of Veterans Affairs hospitals. Using 45 predictor variables, we built a time-dependent Cox proportional hazards model with all-cause mortality as the outcome. We compared performance to the three extant models and reported discrimination and calibration using bootstrapping. Furthermore, we analysed differential utility using the net reclassification index (NRI). Results The C-statistic for the final model was 0.863, representing a significant improvement over the MELD, MELD-Na, and the CLIF-C AD, which had C-statistics of 0.655, 0.675, and 0.679, respectively. Multiple risk factors were significant in our model, including variables reflecting disease severity and haemodynamic compromise. The NRI showed a 24% improvement in predicting survival of low-risk patients and a 30% improvement in predicting death of high-risk patients. Conclusion We developed a more accurate mortality risk prediction score using variables automatically extractable from an EHR that may be used to risk stratify patients with cirrhosis for targeted postdischarge management.
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Affiliation(s)
- Jejo David Koola
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Medicine, University of California San Diego, La Jolla, California, USA.,UC San Diego Health Department of Biomedical Informatics, University of California San Diego, La Jolla, California, United States
| | - Samuel Ho
- Department of Medicine, University of California San Diego, La Jolla, California, USA.,Department of Medicine, VA San Diego Healthcare System, San Diego, California, USA.,Department of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Guanhua Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Amy M Perkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aize Cao
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharon E Davis
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael E Matheny
- Veteran's Health Administration, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Almagro P, Martínez-Camblor P, Miravitlles M, Rodríguez-Carballeira M, Navarro A, Lamprecht B, Ramirez-Garcia Luna AS, Kaiser B, Alfageme I, Casanova C, Esteban C, Soler-Cataluña JJ, de-Torres JP, Celli BR, Marin JM, Ter Riet G, Sobradillo P, Lange P, Garcia-Aymerich J, Anto JM, Turner AM, Han MK, Langhammer A, Sternberg A, Leivseth L, Bakke P, Johannessen A, Oga T, Cosío B, Ancochea J, Echazarreta A, Roche N, Burgel PR, Sin DD, Puhan MA, Soriano JB. External Validation and Recalculation of the CODEX Index in COPD Patients. A 3CIAplus Cohort Study. COPD 2019; 16:8-17. [PMID: 30870059 DOI: 10.1080/15412555.2018.1484440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The CODEX index was developed and validated in patients hospitalized for COPD exacerbation to predict the risk of death and readmission within one year after discharge. Our study aimed to validate the CODEX index in a large external population of COPD patients with variable durations of follow-up. Additionally, we aimed to recalculate the thresholds of the CODEX index using the cutoffs of variables previously suggested in the 3CIA study (mCODEX). Individual data on 2,755 patients included in the COPD Cohorts Collaborative International Assessment Plus (3CIA+) were explored. A further two cohorts (ESMI AND EGARPOC-2) were added. To validate the CODEX index, the relationship between mortality and the CODEX index was assessed using cumulative/dynamic ROC curves at different follow-up periods, ranging from 3 months up to 10 years. Calibration was performed using univariate and multivariate Cox proportional hazard models and Hosmer-Lemeshow test. A total of 3,321 (87.8% males) patients were included with a mean ± SD age of 66.9 ± 10.5 years, and a median follow-up of 1,064 days (IQR 25-75% 426-1643), totaling 11,190 person-years. The CODEX index was statistically associated with mortality in the short- (≤3 months), medium- (≤1 year) and long-term (10 years), with an area under the curve of 0.72, 0.70 and 0.76, respectively. The mCODEX index performed better in the medium-term (<1 year) than the original CODEX, and similarly in the long-term. In conclusion, CODEX and mCODEX index are good predictors of mortality in patients with COPD, regardless of disease severity or duration of follow-up.
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Affiliation(s)
- Pere Almagro
- a Multimorbidity Patients Unit, Internal Medicine , Hospital Universitari Mutua de Terrassa, Universitat de Barcelona , Barcelona , Spain
| | | | - Marc Miravitlles
- c Pneumology Department , Hospital Universitary Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES) , Barcelona , Spain
| | - Mónica Rodríguez-Carballeira
- a Multimorbidity Patients Unit, Internal Medicine , Hospital Universitari Mutua de Terrassa, Universitat de Barcelona , Barcelona , Spain
| | - Annie Navarro
- d Pneumology Service , Hospital Universitari Mútua Terrassa , Barcelona , Spain
| | - Bernd Lamprecht
- e Department of Pulmonary Medicine , Kepler-University-Hospital , Linz , Austria.,f Faculty of Medicine , Johannes-Kepler-University , Linz , Austria
| | | | - Bernhard Kaiser
- h Department of Pulmonary Medicine , Paracelsus Medical University Hospital , Salzburg , Austria
| | - Inmaculada Alfageme
- i Universidad de Sevilla . Departamento de Medicina . HU Virgen de Valme. Sevilla . Spain
| | - Ciro Casanova
- j Hospital Universitario Nuestra Señora de La Candelaria, Universidad de La Laguna , Tenerife , Spain
| | | | | | | | - Bartolome R Celli
- n Pulmonary and Critical Care Medicine , Harvard University, Brigham and Women's Hospital , Boston , MA , USA
| | - Jose M Marin
- o Hospital Universitario Miguel Servet, Zaragoza, and CIBER de Enfermedades Respiratorias (CIBERES) , Spain
| | - Gerben Ter Riet
- p Department of General Practice , Academic Medical Center, University of Amsterdam (AMC) , Amsterdam , The Netherlands
| | - Patricia Sobradillo
- q Hospital Universitario Araba, Sede Txagorritxu, Vitoria, Spain for Universitary Hospital of Cruces in Barakaldo , Spain
| | - Peter Lange
- r Section of Social Medicine, Department of Public Health , Copenhagen University, Copenhagen City Heart Study, Frederiksberg Hospital, Frederiksberg , Copenhagen , Denmark
| | - Judith Garcia-Aymerich
- s ISGlobal , Centre for Research in Environmental Epidemiology (CREAL) , Barcelona , Spain.,t Department of Experimental and Health Sciences , Universitat Pompeu Fabra (UPF) , Barcelona , Spain.,u CIBER Epidemiología y Salud Pública (CIBERESP) , Barcelona , Spain
| | - Josep M Anto
- s ISGlobal , Centre for Research in Environmental Epidemiology (CREAL) , Barcelona , Spain.,t Department of Experimental and Health Sciences , Universitat Pompeu Fabra (UPF) , Barcelona , Spain.,u CIBER Epidemiología y Salud Pública (CIBERESP) , Barcelona , Spain
| | - Alice M Turner
- v Institute of Applied Health Research, University of Birmingham , Edgbaston , UK
| | - MeiLan K Han
- w Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan , Ann Arbor , MI , USA
| | - Arnulf Langhammer
- x Department of Public Health and Nursing , NTNU, Norwegian University of Science and Technology , Trondheim , Norway
| | - Alice Sternberg
- y Department of Epidemiology , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Linda Leivseth
- z Centre for Clinical Documentation and Evaluation , Northern Norway Regional Health Authority , Tromso , Norway
| | - Per Bakke
- aa Department of Clinical Science , University of Bergen , Bergen , Norway
| | - Ane Johannessen
- ab Department of Global Public Health and Primary Care , University of Bergen , Bergen, Bergen , Norway
| | - Toru Oga
- ac Department of Respiratory Care and Sleep Control Medicine , Kyoto University , Kyoto , Japan
| | - Borja Cosío
- ad Department of Respiratory Medicine , Hospital Son Espases-IdISPa, Ciberes, Mallorca , Spain
| | - Julio Ancochea
- ae Servicio de Neumología , Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Cátedra UAM-Linde , Madrid , Spain
| | - Andres Echazarreta
- af Servicio de Neumonología , Hospital San Juan de Dios de La Plata , Buenos Aires , Argentina
| | - Nicolas Roche
- ag Respiratory Medicine, Cochin Hospital APHP, University Paris Descartes , Paris , France
| | - Pierre-Régis Burgel
- ah James Hogg Research Centre , University of British Columbia , Vancouver , BC , Canada
| | - Don D Sin
- ah James Hogg Research Centre , University of British Columbia , Vancouver , BC , Canada.,ai Division of Respiratory Medicine, Department of Medicine , St Paul's Hospital , Vancouver , BC , Canada
| | - Milo A Puhan
- aj Epidemiology , Biostatistics and Prevention Institute, University of Zurich , Zurich , Switzerland
| | - Joan B Soriano
- ak Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Cátedra UAM-Linde , Madrid , Spain
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Antimicrobial prescribing in patients with advanced-stage illness in the antimicrobial stewardship era. Infect Control Hosp Epidemiol 2018; 39:1023-1029. [PMID: 30070197 DOI: 10.1017/ice.2018.167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Antimicrobials are frequently administered to patients with an advanced-stage illness. Understanding the current practice of antimicrobial use at the end of life and the factors influencing physicians' prescribing behavior is necessary to develop an effective antimicrobial stewardship program and to provide optimal end-of-life care for terminally ill patients. DESIGN A 1-year retrospective cohort study. SETTING A public tertiary-care center.PatientsThe study included 260 adult patients who were hospitalized and later died at the study institution with an advanced-stage illness. RESULTS Of 260 patients in our study cohort, 192 (73.8%) had an advanced-stage malignancy and 136 (52.3%) received antimicrobial therapy in the last 14 days of their life; of the latter, 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of life was 421.9 days of therapy per 1,000 patient days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 2.67-8.84) and antipyretic use in the last 14 days of life (aOR, 4.19; 95% CI, 2.01-8.71). CONCLUSION Approximately half of the patients hospitalized with an advanced-stage illness received antimicrobials in the last 14 days of life. The factors associated with antimicrobial use at the end of life in this study are likely to explain physicians' prescribing behaviors. In the current era of antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.
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Frush BW, Brauer SG, Yoon JD, Curlin FA. Physician Decision-Making in the Setting of Advanced Illness: An Examination of Patient Disposition and Physician Religiousness. J Pain Symptom Manage 2018; 55:906-912. [PMID: 29109001 DOI: 10.1016/j.jpainsymman.2017.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Little is known about patient and physician factors that affect decisions to pursue more or less aggressive treatment courses for patients with advanced illness. OBJECTIVES This study sought to determine how patient age, patient disposition, and physician religiousness affect physician recommendations in the context of advanced illness. METHODS A survey was mailed to a stratified random sample of U.S. physicians, which included three vignettes depicting advanced illness scenarios: 1) cancer, 2) heart failure, and 3) dementia with acute infection. One vignette included experimental variables to test how patient age and patient disposition affected physician recommendations. After each vignette, physicians indicated their likelihood to recommend disease-directed medical care vs. hospice care. RESULTS Among eligible physicians (n = 1878), 62% (n = 1156) responded. Patient age and stated patient disposition toward treatment did not significantly affect physician recommendations. Compared with religious physicians, physicians who reported that religious importance was "not applicable" were less likely to recommend chemotherapy (adjusted odds ratio [OR] 0.39, 95% CI 0.23-0.66) and more likely to recommend hospice (OR 1.90, 95% CI 1.15-3.16) for a patient with cancer. Compared with physicians who ever attended religious services, physicians who never attended were less likely to recommend left ventricular assist device placement for a patient with congestive heart failure (OR 0.57, 95% CI 0.35-0.92). In addition, Asian ethnicity was independently associated with recommending chemotherapy (OR 1.72, 95% CI 1.13-2.61) and being less likely to recommend hospice (OR 0.59, 95% CI 0.40-0.91) for the patient with cancer; and it was associated with recommending antibiotics for the patient with dementia and pneumonia (OR 1.64, 95% CI 1.08-2.50). CONCLUSION This study provides preliminary evidence that patient disposition toward more and less aggressive treatment in advanced illness does not substantially factor into physician recommendations. Non-religious physicians appear less likely to recommend disease-directed medical treatment in the setting of advanced illness, although this finding was not uniform and deserves further research.
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Affiliation(s)
- Benjamin W Frush
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Duke Divinity School, Durham, North Carolina, USA.
| | - Simon G Brauer
- Duke University Sociology Department, Durham, North Carolina, USA
| | - John D Yoon
- MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA; Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Farr A Curlin
- Duke Divinity School, Durham, North Carolina, USA; Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
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Hsieh CH, Su CH, Hung SC, Chen WI, Yang LH, Lee CW. Determinant factors of mortality in terminally ill patients with do-not-resuscitate orders. FORMOSAN JOURNAL OF SURGERY 2018. [DOI: 10.4103/fjs.fjs_1_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sasaki A, Hiraoka E, Homma Y, Takahashi O, Norisue Y, Kawai K, Fujitani S. Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients. Int J Gen Med 2017; 10:207-214. [PMID: 28769583 PMCID: PMC5529109 DOI: 10.2147/ijgm.s136921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Code status discussion is associated with a decrease in invasive procedures among terminally ill cancer patients. We investigated the association between code status discussion on admission and incidence of invasive procedures, cardiopulmonary resuscitation (CPR), and opioid use among inpatients with advanced stages of cancer and noncancer diseases. Methods We performed a retrospective cohort study in a single center, Ito Municipal Hospital, Japan. Participants were patients who were admitted to the Department of Internal Medicine between October 1, 2013 and August 30, 2015, with advanced-stage cancer and noncancer. We collected demographic data and inquired the presence or absence of code status discussion within 24 hours of admission and whether invasive procedures, including central venous catheter placement, intubation with mechanical ventilation, and CPR for cardiac arrest, and opioid treatment were performed. We investigated the factors associated with CPR events by using multivariate logistic regression analysis. Results Among the total 232 patients, code status was discussed with 115 patients on admission, of which 114 (99.1%) patients had do-not-resuscitate (DNR) orders. The code status was not discussed with the remaining 117 patients on admission, of which 69 (59%) patients had subsequent code status discussion with resultant DNR orders. Code status discussion on admission decreased the incidence of central venous catheter placement, intubation with mechanical ventilation, and CPR in both cancer and noncancer patients. It tended to increase the rate of opioid use. Code status discussion on admission was the only factor associated with the decreased use of CPR (P<0.001, odds ratio =0.03, 95% CI =0.004–0.21), which was found by using multivariate logistic regression analysis. Conclusion Code status discussion on admission is associated with a decrease in invasive procedures and CPR in cancer and noncancer patients. Physicians should be educated about code status discussion to improve end-of-life care.
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Affiliation(s)
| | | | - Yosuke Homma
- Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba
| | - Osamu Takahashi
- Department of Internal Medicine, St. Luke's International Hospital, Chuo-ku, Tokyo
| | - Yasuhiro Norisue
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba
| | - Koji Kawai
- Department of Gastroenterology, Ito Municipal Hospital, Ito City, Shizuoka, Japan
| | - Shigeki Fujitani
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu City, Chiba
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Almagro P, Yun S, Sangil A, Rodríguez-Carballeira M, Marine M, Landete P, Soler-Cataluña JJ, Soriano JB, Miravitlles M. Palliative care and prognosis in COPD: a systematic review with a validation cohort. Int J Chron Obstruct Pulmon Dis 2017; 12:1721-1729. [PMID: 28652724 PMCID: PMC5473497 DOI: 10.2147/copd.s135657] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Current recommendations to consider initiation of palliative care (PC) in COPD patients are often based on an expected poor prognosis. However, this approach is not evidence-based, and which and when COPD patients should start PC is controversial. We aimed to assess whether current suggested recommendations for initiating PC were sufficiently reliable. We identified prognostic variables proposed in the literature for initiating PC; then, we ascertained their relationship with 1-year mortality, and finally, we validated their utility in our cohort of 697 patients hospitalized for COPD exacerbation. From 24 articles of 499 screened, we selected 20 variables and retrieved 48 original articles in which we were able to calculate the relationship between each of them and 1-year mortality. The number of studies where 1-year mortality was detailed for these variables ranged from 9 for previous hospitalizations or FEV1 ≤30% to none for albumin ≤25 mg/dL. The percentage of 1-year mortality in the literature for these variables ranged from 5% to 60%. In the validation cohort study, the prevalence of these proposed variables ranged from 8% to 64%; only 10 of the 18 variables analyzed in our cohort reached statistical significance with Cox regression analysis, and none overcame an area under the curve ≥0.7. We conclude that none of the suggested criteria for initiating PC based on an expected poor vital prognosis in COPD patients in the short or medium term offers sufficient reliability, and consequently, they should be avoided as exclusive criteria for considering PC or at least critically appraised.
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Affiliation(s)
- Pere Almagro
- Multimorbidity Patients Unit, Internal Medicine Department, Hospital Universitario Mutua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona
| | - Sergi Yun
- Multimorbidity Patients Unit, Internal Medicine Department, Hospital Universitario Mutua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona
| | - Ana Sangil
- Multimorbidity Patients Unit, Internal Medicine Department, Hospital Universitario Mutua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona
| | - Mónica Rodríguez-Carballeira
- Multimorbidity Patients Unit, Internal Medicine Department, Hospital Universitario Mutua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona
| | - Meritxell Marine
- Multimorbidity Patients Unit, Internal Medicine Department, Hospital Universitario Mutua de Terrassa, Universidad de Barcelona, Terrassa, Barcelona
| | - Pedro Landete
- Department of Pneumology, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid
| | | | - Joan B Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid
| | - Marc Miravitlles
- Department of Pneumology, Vall d'Hebron University Hospital, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Bassetti M, Peghin M, Carnelutti A, Righi E, Merelli M, Ansaldi F, Trucchi C, Alicino C, Sartor A, Toniutto P, Wauters J, Laleman W, Tascini C, Menichetti F, Luzzati R, Brugnaro P, Mesini A, Raviolo S, De Rosa FG, Lagunes L, Rello J, Dimopoulos G, Colombo AL, Nucci M, Vena A, Bouza E, Muñoz P, Tumbarello M, Losito R, Martin-Loeches I, Viscoli C. Clinical characteristics and predictors of mortality in cirrhotic patients with candidemia and intra-abdominal candidiasis: a multicenter study. Intensive Care Med 2017; 43:509-518. [DOI: 10.1007/s00134-017-4717-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/07/2017] [Indexed: 12/23/2022]
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Patel JJ, McClain CJ, Sarav M, Hamilton-Reeves J, Hurt RT. Protein Requirements for Critically Ill Patients With Renal and Liver Failure. Nutr Clin Pract 2017; 32:101S-111S. [PMID: 28208022 DOI: 10.1177/0884533616687501] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Diseases leading to critical illness induce proteolysis resulting in muscle wasting and negative nitrogen balance. Muscle wasting has been associated with poor intensive care unit (ICU)-related outcomes, including an increased risk for mortality. Acute kidney injury (AKI) represents a common organ dysfunction associated with ICU-related disorders, such as sepsis, trauma, and respiratory failure. AKI and renal replacement therapy lead to amino acid loss. Decompensated liver cirrhosis (DLC) and acute liver failure (ALF) represent more severe forms of liver dysfunction leading to ICU admission. DLC and ALF are associated with proteolysis and amino acid loss. AKI, DLC, and ALF uniquely contribute to negative nitrogen balance. The purpose of this review is to outline proteolysis associated with critical illness; define specific protein abnormalities in AKI, DLC, and ALF; define protein requirements in AKI, DLC, and ALF; and discuss barriers associated with optimal protein supplementation in these disorders.
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Affiliation(s)
- Jayshil J Patel
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig J McClain
- 2 Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Department of Pharmacology and Toxicology, University of Louisville, and Robley Rex VA Medical Center, Louisville, Kentucky, USA
| | - Menaka Sarav
- 3 Division of Nephrology, Department of Medicine, NorthShore University Hospital Health System, University of Chicago, Chicago, Illinois, USA
| | - Jill Hamilton-Reeves
- 4 Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ryan T Hurt
- 5 Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Ruiz-Laiglesia F, Garcés-Horna V, Formiga F. Comprehensive therapeutic approach for patients with heart failure and comorbidity. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2015.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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32
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Pengo V, Zurlo A, Voci A, Valentini E, De Zaiacomo F, Catarini M, Iasevoli M, Maggi S, Pegoraro R, Manzato E, Giantin V. Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies. Geriatr Gerontol Int 2016; 17:487-493. [PMID: 27004847 DOI: 10.1111/ggi.12746] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/23/2015] [Accepted: 12/22/2015] [Indexed: 11/30/2022]
Abstract
AIM The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls. METHODS End-of-life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN. RESULTS When the patient's life expectancy was 1-6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN. CONCLUSIONS The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487-493.
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Affiliation(s)
- Valentina Pengo
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | - Anna Zurlo
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | - Alberto Voci
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova, Padova, Italy
| | - Elisabetta Valentini
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | | | | | - Mario Iasevoli
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
| | - Stefania Maggi
- Aging Section, Institute of Neurosciences, Italian Research Council, Padova, Italy
| | | | - Enzo Manzato
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy.,Aging Section, Institute of Neurosciences, Italian Research Council, Padova, Italy
| | - Valter Giantin
- Geriatrics Division, Department of Medicine, University of Padova, Padova, Italy
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Orkaby AR, Forman DE. Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity. Clin Geriatr Med 2016; 32:359-71. [PMID: 27113152 DOI: 10.1016/j.cger.2016.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Age-related cardiovascular disease in older adults is more likely to occur in combination with other age-related diseases, with mounting interactive complexity as multiple morbidities accumulate. Although invasive cardiac procedures are frequently recommended for cardiovascular disease, their value is less certain in the context of age-related intricacies of care. Tools for risk assessment before invasive procedures are insensitive to risks corresponding to the unique challenges of older adults. Recognizing multimorbidity and other age-related risks provides opportunities to intervene and moderate dangers. By refocusing risk assessment in terms of patient-centered goals, the fundamental utility of invasive cardiac procedures may be reconsidered and alternative therapies prioritized.
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Affiliation(s)
- Ariela R Orkaby
- Division of Cardiology, VA Boston Healthcare System, 400 Veterans of Foreign Wars Pkwy, West Roxbury, MA 02132, USA; Division of Aging, Brigham & Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213, USA; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Dr C, Pittsburgh, PA 15240, USA.
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Ruiz-Laiglesia FJ, Garcés-Horna V, Formiga F. Comprehensive therapeutic approach for patients with heart failure and comorbidity. Rev Clin Esp 2015; 216:323-30. [PMID: 26552747 DOI: 10.1016/j.rce.2015.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 09/28/2015] [Indexed: 01/11/2023]
Abstract
The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype». Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.
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Affiliation(s)
- F J Ruiz-Laiglesia
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón, Zaragoza, España.
| | - V Garcés-Horna
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Instituto de Investigación Sanitaria de Aragón, Zaragoza, España
| | - F Formiga
- Departamento de Medicina Interna, Hospital Universitario de Bellvitge. Instituto de Investigación Biomédica de Bellvitge, Hospitalet de Llobregat, Barcelona, España
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Gavazzi A, De Maria R, Manzoli L, Bocconcelli P, Di Leonardo A, Frigerio M, Gasparini S, Humar F, Perna G, Pozzi R, Svanoni F, Ugolini M, Deales A. Palliative needs for heart failure or chronic obstructive pulmonary disease: Results of a multicenter observational registry. Int J Cardiol 2015; 184:552-558. [DOI: 10.1016/j.ijcard.2015.03.056] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 01/26/2015] [Accepted: 03/03/2015] [Indexed: 01/07/2023]
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Schwartz JB. Primary prevention: do the very elderly require a different approach? Trends Cardiovasc Med 2015; 25:228-39. [PMID: 25560975 PMCID: PMC4374025 DOI: 10.1016/j.tcm.2014.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 01/21/2023]
Abstract
Recent cardiovascular prevention guidelines place a greater emphasis on randomized placebo-controlled trial data as the basis for recommendations. While such trial data are sparse for people over the age of 75 or 80 years, data demonstrate altered risk-benefit relationships in these older patients. Primary prevention strategy decisions should consider estimated life expectancy and overall function as well as cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. Data support treatment of systolic hypertension to reduce stroke, cardiovascular events, and dementia in older patients with at least a 2-year estimated lifespan with modifications in systolic blood pressure goals and a need for greater attention to non-cardiovascular side effects such as falls in the very old. Lowering of elevated cholesterol levels with HMG-CoA reductase inhibitors for primary prevention in people over the age of 75 years requires greater individual considerations, as benefits may not accrue for 3-5 years and there is the potential impact of adverse effects. There is a rationale for lipid-lowering treatment in the more highly functional older patient with cardiovascular (especially stroke) risk higher than side effect risks in the near term and with an estimated lifespan longer than the time to benefit. Aspirin has higher side effect risks and requires a longer time to achieve benefit. Trial data are lacking on exercise interventions, but multi-system benefits have been shown in older patients such that exercise should be part of a preventive regimen. Preventive therapy in the very old means considering not only medical issues of co-morbidities, polypharmacy, and altered risk-benefit relationship of medications but also adjusting goals and approaches across the older agespan in keeping with informed patient preferences.
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Affiliation(s)
- Janice B Schwartz
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Jewish Home of San Francisco, San Francisco, CA; Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA.
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Abstract
Primary care physicians are often the first medical providers patients seek out, and are in an excellent position to provide primary palliative care. Primary palliative care encompasses basic skills including basic evaluation and management of symptoms and discussions about goals of care and advance care planning. Specialty palliative care consultation complements primary care by assisting with complex psychosocial-spiritual patient and family situations. This article reviews primary palliative care skill sets and criteria for when to consider referring patients to specialty palliative care and hospice services.
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Affiliation(s)
- Amrita Ghosh
- Pain and Palliative Care Service, 10 Center Drive, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - Elizabeth Dzeng
- Division of General Internal Medicine, Program in Palliative Care, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 359, Baltimore, MD 21287, USA; University of Cambridge School of Clinical Medicine, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - M Jennifer Cheng
- Pain and Palliative Care Service, 10 Center Drive, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA.
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Walling AM, Schreibeis-Baum H, Pimstone N, Asch SM, Robinson L, Korlekar S, Lorenz K, Nwajuaku T, Rosenfeld K. Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. J Palliat Med 2014. [PMID: 25493552 DOI: 10.1089/jpm.2014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention. METHODS We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC. RESULTS We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38). CONCLUSIONS Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
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Affiliation(s)
- Anne M Walling
- 1 Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California , Los Angeles, California
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39
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Walling AM, Schreibeis-Baum H, Pimstone N, Asch SM, Robinson L, Korlekar S, Lorenz K, Nwajuaku T, Rosenfeld K. Proactive case finding to improve concurrently curative and palliative care in patients with end-stage liver disease. J Palliat Med 2014; 18:378-81. [PMID: 25493552 DOI: 10.1089/jpm.2014.0265] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Palliative care and preparation for liver transplantation are often perceived as conflicting for patients with end-stage liver disease (ESLD). We sought to improve both simultaneously through a case finding and care coordination quality improvement intervention. METHODS We identified patients with cirrhosis using validated ICD-9 codes and screened them for ESLD by assessing medical records at a VA hospital for either a model for end-stage liver disease (MELD) ≥14 or a diagnosis of hepatocellular carcinoma (HCC) between October 2012 and January 2013. A care coordinator followed veterans from the index hospitalization through April 2013 and encouraged treating physicians to submit liver transplant evaluation consults for all veterans with a MELD ≥14 and palliative care consults for all veterans with a MELD ≥20 or inoperable HCC. RESULTS We compared rates of consultation for 49 hospitalized veterans and compared their outcomes to 61 pre-intervention veterans. Veterans were more likely to be considered for liver transplantation (77.6% versus 31.1%, p<0.001) and receive palliative care consultation during the intervention period, although the latter finding did not reach statistical significance (62.5% versus 47.1%, p=0.38). CONCLUSIONS Active case finding improved consideration for liver transplantation without decreasing palliative care consultation.
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Affiliation(s)
- Anne M Walling
- 1 Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California , Los Angeles, California
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Lindman BR, Alexander KP, O'Gara PT, Afilalo J. Futility, benefit, and transcatheter aortic valve replacement. JACC Cardiovasc Interv 2014; 7:707-16. [PMID: 24954571 DOI: 10.1016/j.jcin.2014.01.167] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 01/30/2014] [Indexed: 11/16/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a transformative innovation that provides treatment for high or prohibitive surgical risk patients with symptomatic severe aortic stenosis who either were previously not referred for or were denied operative intervention. Trials have demonstrated improvements in survival and symptoms after TAVR versus medical therapy; however, there remains a sizable group of patients who die or lack improvement in quality of life soon after TAVR. This raises important questions about the need to identify and acknowledge the possibility of futility in some patients considered for TAVR. In this very elderly population, a number of factors in addition to traditional risk stratification need to be considered including multimorbidity, disability, frailty, and cognition in order to assess the anticipated benefit of TAVR. Consideration by a multidisciplinary heart valve team with broad areas of expertise is critical for assessing likely benefit from TAVR. Moreover, these complicated decisions should take place with clear communication around desired health outcomes on behalf of the patient and provider. The decision that treatment with TAVR is futile should include alternative plans to optimize the patient's health state or, in some cases, discussions related to end-of-life care. We review issues to be considered when making and communicating these difficult decisions.
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Affiliation(s)
- Brian R Lindman
- Washington University School of Medicine, St. Louis, Missouri.
| | | | - Patrick T O'Gara
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Afilalo
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Barceló M, Torres O, Ruiz D, Casademont J. Appropriateness of Medications Prescribed to Elderly Patients with Advanced Heart Failure and Limited Life Expectancy Who Died During Hospitalization. Drugs Aging 2014; 31:541-6. [DOI: 10.1007/s40266-014-0183-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lee PC, Lo C, Ko WJ, Huang SJ, Lee PH. When and how should physicians determine the need for palliative and hospice care for patients with end-stage liver disease?: an experience in Taiwan. Am J Hosp Palliat Care 2013; 31:454-8. [PMID: 23861543 DOI: 10.1177/1049909113495707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We analyzed one case of end-stage liver disease and discussed whether the palliative care should be considered for this case. The medical record of a 56-year-old woman with alcoholic liver cirrhosis admitted to our hospital due to hypovolemic shock and esophageal varices (EV) was reviewed. The EV with active bleeding were arrested by panendoscopic intervention. However, repeat surgery revealed transmural laceration over the cardia, and immediate surgery and splenectomy were needed. The patient died postoperatively in the surgical intensive care unit due to bleeding tendency and hypovolemic shock. We suggest that palliative care and/or hospice care should have been considered for this patient before the crisis developed and that physicians require education about timely palliative and hospice care for patients with end-stage nonmalignant disease.
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Affiliation(s)
- Po-Chu Lee
- 1Department of Trauma, National Taiwan University Hospital, Taipei, Taiwan
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Brown MA, Sampson EL, Jones L, Barron AM. Prognostic indicators of 6-month mortality in elderly people with advanced dementia: a systematic review. Palliat Med 2013; 27:389-400. [PMID: 23175514 PMCID: PMC3652641 DOI: 10.1177/0269216312465649] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For end-of-life dementia patients, palliative care offers a better quality of life than continued aggressive or burdensome medical interventions. To provide the best care options to dementia sufferers, validated, reliable, sensitive, and accurate prognostic tools to identify end-of-life dementia stages are necessary. AIM To identify accurate prognosticators of mortality in elderly advanced dementia patients consistently reported in the literature. DESIGN Systematic literature review. DATA SOURCES PubMed, Embase, and PsycINFO databases were searched up to September 2012. Reference lists of included studies were also searched. Inclusion criteria were studies measuring factors specifically related to 6-month outcome in patients diagnosed with dementia in any residential or health-care setting. RESULTS Seven studies met the inclusion criteria, five of which were set in the United States and two in Israel. Methodology and prognostic outcomes varied greatly between the studies. All but one study found that Functional Assessment Staging phase 7c, currently widely used to assess hospice admission eligibility in the United States, was not a reliable predictor of 6-month mortality. The most common prognostic variables identified related to nutrition/nourishment, or eating habits, followed by increased risk on dementia severity scales and comorbidities. CONCLUSIONS Although the majority of studies agreed that the Functional Assessment Staging 7c criterion was not a reliable predictor of 6-month mortality, we found a lack of prognosticator concordance across the literature. Further studies are essential to identify reliable, sensitive, and specific prognosticators, which can be applied to the clinical setting and allow increased availability of palliative care to dementia patients.
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Affiliation(s)
- Meghan A Brown
- Department of Neuroscience, College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, USA
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2012. [DOI: 10.1089/jpm.2012.9568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Systematic Review of Cancer Presentations with a Median Survival of Six Months or Less. J Palliat Med 2012; 15:175-85. [DOI: 10.1089/jpm.2011.0192] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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