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Beauverd M, Mazzoli M, Pralong J, Tomczyk M, Eychmüller S, Gaertner J. Palliative sedation - revised recommendations. Swiss Med Wkly 2024; 154:3590. [PMID: 38579308 DOI: 10.57187/s.3590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study. Inadequately trained and inexperienced healthcare professionals may incorrectly or inappropriately perform palliative sedation due to uncertainties regarding its definitions and practice. Therefore, the expert members of the Bigorio group and the authors of this manuscript believe that national recommendations should be published and made available to healthcare professionals to provide practical, terminological, and ethical guidance. The Bigorio group is the working group of the Swiss Palliative Care Society whose task is to publish clinical recommendations at a national level in Switzerland. These recommendations aim to provide guidance on the most critical questions and issues related to palliative sedation. The Swiss Society of Palliative Care (palliative.ch) mandated a writing board comprising four clinical experts (three physicians and one ethicist) and two national academic experts to revise the 2005 Bigorio guidelines. A first draft was created based on a narrative literature review, which was internally reviewed by five academic institutions (Lausanne, Geneva, Bern, Zürich, and Basel) and the heads of all working groups of the Swiss Society of Palliative Care before finalising the guidelines. The following themes are discussed regarding palliative sedation: (a) definitions and clinical aspects, (b) the decision-making process, (c) communication with patients and families, (d) patient monitoring, (e) pharmacological approaches, and (f) ethical and controversial issues. Palliative sedation must be practised with clinical and ethical accuracy and competence to avoid harm and ethically questionable use. Specialist palliative care teams should be consulted before initiating palliative sedation to avoid overlooking other potential treatment options for the patient's symptoms and suffering.
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Affiliation(s)
- Michel Beauverd
- Service de soins palliatifs et de support, Département de médecine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | | | | | - Martyna Tomczyk
- Institute of Humanities in Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Steffen Eychmüller
- Universitäres Zentrum für Palliative Care (UZP), Inselspital, University Hospital, Bern, Switzerland
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Department of Clinical Research, University of Basel, Switzerland
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Gut S, Rauch M, Haschke M, Huber CA, Gaertner J, Schur N, Meier CR, Spoendlin J. Use of metamizole and other non-opioid analgesics in Switzerland between 2014 and 2019: an observational study using a large health insurance claims database. Swiss Med Wkly 2024; 154:3535. [PMID: 38579298 DOI: 10.57187/s.3535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
OBJECTIVE To investigate claims patterns for metamizole and other non-opioid analgesics in Switzerland. To characterise users of these non-opioid analgesics regarding sex, age, comedications and canton of residence. METHODS We conducted a retrospective descriptive study using administrative claims data of outpatient prescribed non-opioid analgesics of the Swiss health insurance company Helsana between January 2014 and December 2019. First, we evaluated the number of claims and defined daily doses per year of metamizole, ibuprofen, diclofenac and paracetamol in adults aged 18 years or over. Second, we characterised new users of these non-opioid analgesics in terms of sex, age, claimed comedications and canton of residence. RESULTS From 2014 to 2019, among the investigated non-opioid analgesics, metamizole showed the highest increase in claims (+9545 claims, +50%) and defined daily doses (+86,869 defined daily doses, +84%) per 100,000 adults. Metamizole users had the highest median age (62 years [IQR: 44-77]) compared to ibuprofen (47 years [IQR: 33-62]), diclofenac (57 years [IQR: 43-71]) and paracetamol (58 years [IQR: 39-75]) users. Metamizole users also more frequently claimed proton pump inhibitors, anticoagulants, platelet aggregation inhibitors and antihypertensive drugs than users of other non-opioid analgesics. While metamizole was most frequently claimed in German-speaking regions of Switzerland, ibuprofen and paracetamol were most frequently claimed in the French-speaking regions and diclofenac in German- and Italian-speaking regions. CONCLUSION In Switzerland, metamizole was increasingly claimed between 2014 and 2019. Metamizole was most frequently claimed by older adults and patients with comedications suggestive of underlying conditions, which can be worsened or caused by use of nonsteroidal anti-inflammatory drugs. The lack of studies regarding the effectiveness and safety of metamizole in this population warrants further investigation.
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Affiliation(s)
- Stephan Gut
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Marlene Rauch
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Manuel Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, University Hospital Bern, University of Bern, Switzerland
| | - Carola A Huber
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Jan Gaertner
- Palliative care center Hildegard, Basel, Switzerland
| | - Nadine Schur
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Christoph R Meier
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
| | - Julia Spoendlin
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
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Gaertner J, Witte KK. Potential role of pregabalin in the treatment of episodic breathlessness. Ann Palliat Med 2024; 13:200-201. [PMID: 38073296 DOI: 10.21037/apm-23-547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/30/2023] [Indexed: 02/07/2024]
Affiliation(s)
- Jan Gaertner
- Palliative Care Center Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Klaus K Witte
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, Aachen, Germany; Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Smaling HJ, Jingyuan X, Nakanishi M, Shinan-Altman S, Mehr DR, Radbruch L, Gaertner J, Werner P, Achterberg WP, van der Steen JT. Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing. BMC Palliat Care 2023; 22:142. [PMID: 37752467 PMCID: PMC10523619 DOI: 10.1186/s12904-023-01249-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner. METHODS Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction. DISCUSSION In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful. TRIAL REGISTRATION The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.
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Affiliation(s)
- Hanneke J.A. Smaling
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands
| | - Xu Jingyuan
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
| | - Miharu Nakanishi
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - David R. Mehr
- Department of Family and Community Medicine, University of Missouri, Columbia, MO USA
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Centre for Palliative Medicine, Helios Hospital Bonn/Rhein-Sieg, Bonn, Germany
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Perla Werner
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Wilco P. Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- University Network for the Care sector Zuid-Holland, Leiden University Medical Center, Leiden, The Netherlands
- Center for Old Age Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jenny T. van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Gebouw 3, Postal zone V0-P, P.O. Box 9600, Leiden, 2300 RC The Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
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Gaertner J, Fusi-Schmidhauser T, Stock S, Siemens W, Vennedey V. Effect of opioids for breathlessness in heart failure: a systematic review and meta-analysis. Heart 2023; 109:1064-1071. [PMID: 36878671 PMCID: PMC10359514 DOI: 10.1136/heartjnl-2022-322074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/19/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND For the treatment of breathlessness in heart failure (HF), most textbooks advocate the use of opioids. Yet, meta-analyses are lacking. METHODS A systematic review was performed for randomised controlled trials (RCTs) assessing effects of opioids on breathlessness (primary outcome) in patients with HF. Key secondary outcomes were quality of life (QoL), mortality and adverse effects. Cochrane Central Register of Controlled Trials, MEDLINE and Embase were searched in July 2021. Risk of bias (RoB) and certainty of evidence were assessed by the Cochrane RoB 2 Tool and Grading of Recommendations Assessment, Development and Evaluation criteria, respectively. The random-effects model was used as primary analysis in all meta-analyses. RESULTS After removal of duplicates, 1180 records were screened. We identified eight RCTs with 271 randomised patients. Seven RCTs could be included in the meta-analysis for the primary endpoint breathlessness with a standardised mean difference of 0.03 (95% CI -0.21 to 0.28). No study found statistically significant differences between the intervention and placebo. Several key secondary outcomes favoured placebo: risk ratio of 3.13 (95% CI 0.70 to 14.07) for nausea, 4.29 (95% CI 1.15 to 16.01) for vomiting, 4.77 (95% CI 1.98 to 11.53) for constipation and 4.42 (95% CI 0.79 to 24.87) for study withdrawal. All meta-analyses revealed low heterogeneity (I2 in all these meta-analyses was <8%). CONCLUSION Opioids for treating breathlessness in HF are questionable and may only be the very last option if other options have failed or in case of an emergency. PROSPERO REGISTRATION NUMBER CRD42021252201.
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Affiliation(s)
- Jan Gaertner
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Center for Palliative Care Hildegard, Basel, Switzerland
| | - Tanja Fusi-Schmidhauser
- Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland IOSI-EOC, Lugano, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, University Hospital Cologne, Cologne, Germany
| | - Waldemar Siemens
- Institute for Evidence in Medicine, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Vera Vennedey
- Institute of Health Economics and Clinical Epidemiology, University Hospital Cologne, Cologne, Germany
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Gaertner J, Zimmermann F, Simone CB. The value of patient reported outcomes in palliative radiotherapy: A discussion in light of current findings. Ann Palliat Med 2023:apm-23-147. [PMID: 37026363 DOI: 10.21037/apm-23-147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland; Medical Faculty, University of Basel, Basel, Switzerland
| | - Frank Zimmermann
- Medical Faculty, University of Basel, Basel, Switzerland; University Hospital Basel, Clinic of Radiotherapy and Radiation Oncology, Switzerland
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Proietti M, Romiti GF, Vitolo M, Harrison SL, Lane DA, Fauchier L, Marin F, Näbauer M, Potpara TS, Dan GA, Maggioni AP, Cesari M, Boriani G, Lip GYH, Ekmekçiu U, Paparisto V, Tase M, Gjergo H, Dragoti J, Goda A, Ciutea M, Ahadi N, el Husseini Z, Raepers M, Leroy J, Haushan P, Jourdan A, Lepiece C, Desteghe L, Vijgen J, Koopman P, Van Genechten G, Heidbuchel H, Boussy T, De Coninck M, Van Eeckhoutte H, Bouckaert N, Friart A, Boreux J, Arend C, Evrard P, Stefan L, Hoffer E, Herzet J, Massoz M, Celentano C, Sprynger M, Pierard L, Melon P, Van Hauwaert B, Kuppens C, Faes D, Van Lier D, Van Dorpe A, Gerardy A, Deceuninck O, Xhaet O, Dormal F, Ballant E, Blommaert D, Yakova D, Hristov M, Yncheva T, Stancheva N, Tisheva S, Tokmakova M, Nikolov F, Gencheva D, Shalganov T, Kunev B, Stoyanov M, Marchov D, Gelev V, Traykov V, Kisheva A, Tsvyatkov H, Shtereva R, Bakalska-Georgieva S, Slavcheva S, Yotov Y, Kubíčková M, Marni Joensen A, Gammelmark A, Hvilsted Rasmussen L, Dinesen P, Riahi S, Krogh Venø S, Sorensen B, Korsgaard A, Andersen K, Fragtrup Hellum C, Svenningsen A, Nyvad O, Wiggers P, May O, Aarup A, Graversen B, Jensen L, Andersen M, Svejgaard M, Vester S, Hansen S, Lynggaard V, Ciudad M, Vettus R, Muda P, Maestre A, Castaño S, Cheggour S, Poulard J, Mouquet V, Leparrée S, Bouet J, Taieb J, Doucy A, Duquenne H, Furber A, Dupuis J, Rautureau J, Font M, Damiano P, Lacrimini M, Abalea J, Boismal S, Menez T, Mansourati J, Range G, Gorka H, Laure C, Vassalière C, Elbaz N, Lellouche N, Djouadi K, Roubille F, Dietz D, Davy J, Granier M, Winum P, Leperchois-Jacquey C, Kassim H, Marijon E, Le Heuzey J, Fedida J, Maupain C, Himbert C, Gandjbakhch E, Hidden-Lucet F, Duthoit G, Badenco N, Chastre T, Waintraub X, Oudihat M, Lacoste J, Stephan C, Bader H, Delarche N, Giry L, Arnaud D, Lopez C, Boury F, Brunello I, Lefèvre M, Mingam R, Haissaguerre M, Le Bidan M, Pavin D, Le Moal V, Leclercq C, Piot O, Beitar T, Martel I, Schmid A, Sadki N, Romeyer-Bouchard C, Da Costa A, Arnault I, Boyer M, Piat C, Fauchier L, Lozance N, Nastevska S, Doneva A, Fortomaroska Milevska B, Sheshoski B, Petroska K, Taneska N, Bakrecheski N, Lazarovska K, Jovevska S, Ristovski V, Antovski A, Lazarova E, Kotlar I, Taleski J, Poposka L, Kedev S, Zlatanovik N, Jordanova S, Bajraktarova Proseva T, Doncovska S, Maisuradze D, Esakia A, Sagirashvili E, Lartsuliani K, Natelashvili N, Gumberidze N, Gvenetadze R, Etsadashvili K, Gotonelia N, Kuridze N, Papiashvili G, Menabde I, Glöggler S, Napp A, Lebherz C, Romero H, Schmitz K, Berger M, Zink M, Köster S, Sachse J, Vonderhagen E, Soiron G, Mischke K, Reith R, Schneider M, Rieker W, Boscher D, Taschareck A, Beer A, Oster D, Ritter O, Adamczewski J, Walter S, Frommhold A, Luckner E, Richter J, Schellner M, Landgraf S, Bartholome S, Naumann R, Schoeler J, Westermeier D, William F, Wilhelm K, Maerkl M, Oekinghaus R, Denart M, Kriete M, Tebbe U, Scheibner T, Gruber M, Gerlach A, Beckendorf C, Anneken L, Arnold M, Lengerer S, Bal Z, Uecker C, Förtsch H, Fechner S, Mages V, Martens E, Methe H, Schmidt T, Schaeffer B, Hoffmann B, Moser J, Heitmann K, Willems S, Willems S, Klaus C, Lange I, Durak M, Esen E, Mibach F, Mibach H, Utech A, Gabelmann M, Stumm R, Ländle V, Gartner C, Goerg C, Kaul N, Messer S, Burkhardt D, Sander C, Orthen R, Kaes S, Baumer A, Dodos F, Barth A, Schaeffer G, Gaertner J, Winkler J, Fahrig A, Aring J, Wenzel I, Steiner S, Kliesch A, Kratz E, Winter K, Schneider P, Haag A, Mutscher I, Bosch R, Taggeselle J, Meixner S, Schnabel A, Shamalla A, Hötz H, Korinth A, Rheinert C, Mehltretter G, Schön B, Schön N, Starflinger A, Englmann E, Baytok G, Laschinger T, Ritscher G, Gerth A, Dechering D, Eckardt L, Kuhlmann M, Proskynitopoulos N, Brunn J, Foth K, Axthelm C, Hohensee H, Eberhard K, Turbanisch S, Hassler N, Koestler A, Stenzel G, Kschiwan D, Schwefer M, Neiner S, Hettwer S, Haeussler-Schuchardt M, Degenhardt R, Sennhenn S, Steiner S, Brendel M, Stoehr A, Widjaja W, Loehndorf S, Logemann A, Hoskamp J, Grundt J, Block M, Ulrych R, Reithmeier A, Panagopoulos V, Martignani C, Bernucci D, Fantecchi E, Diemberger I, Ziacchi M, Biffi M, Cimaglia P, Frisoni J, Boriani G, Giannini I, Boni S, Fumagalli S, Pupo S, Di Chiara A, Mirone P, Fantecchi E, Boriani G, Pesce F, Zoccali C, Malavasi VL, Mussagaliyeva A, Ahyt B, Salihova Z, Koshum-Bayeva K, Kerimkulova A, Bairamukova A, Mirrakhimov E, Lurina B, Zuzans R, Jegere S, Mintale I, Kupics K, Jubele K, Erglis A, Kalejs O, Vanhear K, Burg M, Cachia M, Abela E, Warwicker S, Tabone T, Xuereb R, Asanovic D, Drakalovic D, Vukmirovic M, Pavlovic N, Music L, Bulatovic N, Boskovic A, Uiterwaal H, Bijsterveld N, De Groot J, Neefs J, van den Berg N, Piersma F, Wilde A, Hagens V, Van Es J, Van Opstal J, Van Rennes B, Verheij H, Breukers W, Tjeerdsma G, Nijmeijer R, Wegink D, Binnema R, Said S, Erküner Ö, Philippens S, van Doorn W, Crijns H, Szili-Torok T, Bhagwandien R, Janse P, Muskens A, van Eck M, Gevers R, van der Ven N, Duygun A, Rahel B, Meeder J, Vold A, Holst Hansen C, Engset I, Atar D, Dyduch-Fejklowicz B, Koba E, Cichocka M, Sokal A, Kubicius A, Pruchniewicz E, Kowalik-Sztylc A, Czapla W, Mróz I, Kozlowski M, Pawlowski T, Tendera M, Winiarska-Filipek A, Fidyk A, Slowikowski A, Haberka M, Lachor-Broda M, Biedron M, Gasior Z, Kołodziej M, Janion M, Gorczyca-Michta I, Wozakowska-Kaplon B, Stasiak M, Jakubowski P, Ciurus T, Drozdz J, Simiera M, Zajac P, Wcislo T, Zycinski P, Kasprzak J, Olejnik A, Harc-Dyl E, Miarka J, Pasieka M, Ziemińska-Łuć M, Bujak W, Śliwiński A, Grech A, Morka J, Petrykowska K, Prasał M, Hordyński G, Feusette P, Lipski P, Wester A, Streb W, Romanek J, Woźniak P, Chlebuś M, Szafarz P, Stanik W, Zakrzewski M, Kaźmierczak J, Przybylska A, Skorek E, Błaszczyk H, Stępień M, Szabowski S, Krysiak W, Szymańska M, Karasiński J, Blicharz J, Skura M, Hałas K, Michalczyk L, Orski Z, Krzyżanowski K, Skrobowski A, Zieliński L, Tomaszewska-Kiecana M, Dłużniewski M, Kiliszek M, Peller M, Budnik M, Balsam P, Opolski G, Tymińska A, Ozierański K, Wancerz A, Borowiec A, Majos E, Dabrowski R, Szwed H, Musialik-Lydka A, Leopold-Jadczyk A, Jedrzejczyk-Patej E, Koziel M, Lenarczyk R, Mazurek M, Kalarus Z, Krzemien-Wolska K, Starosta P, Nowalany-Kozielska E, Orzechowska A, Szpot M, Staszel M, Almeida S, Pereira H, Brandão Alves L, Miranda R, Ribeiro L, Costa F, Morgado F, Carmo P, Galvao Santos P, Bernardo R, Adragão P, Ferreira da Silva G, Peres M, Alves M, Leal M, Cordeiro A, Magalhães P, Fontes P, Leão S, Delgado A, Costa A, Marmelo B, Rodrigues B, Moreira D, Santos J, Santos L, Terchet A, Darabantiu D, Mercea S, Turcin Halka V, Pop Moldovan A, Gabor A, Doka B, Catanescu G, Rus H, Oboroceanu L, Bobescu E, Popescu R, Dan A, Buzea A, Daha I, Dan G, Neuhoff I, Baluta M, Ploesteanu R, Dumitrache N, Vintila M, Daraban A, Japie C, Badila E, Tewelde H, Hostiuc M, Frunza S, Tintea E, Bartos D, Ciobanu A, Popescu I, Toma N, Gherghinescu C, Cretu D, Patrascu N, Stoicescu C, Udroiu C, Bicescu G, Vintila V, Vinereanu D, Cinteza M, Rimbas R, Grecu M, Cozma A, Boros F, Ille M, Tica O, Tor R, Corina A, Jeewooth A, Maria B, Georgiana C, Natalia C, Alin D, Dinu-Andrei D, Livia M, Daniela R, Larisa R, Umaar S, Tamara T, Ioachim Popescu M, Nistor D, Sus I, Coborosanu O, Alina-Ramona N, Dan R, Petrescu L, Ionescu G, Popescu I, Vacarescu C, Goanta E, Mangea M, Ionac A, Mornos C, Cozma D, Pescariu S, Solodovnicova E, Soldatova I, Shutova J, Tjuleneva L, Zubova T, Uskov V, Obukhov D, Rusanova G, Soldatova I, Isakova N, Odinsova S, Arhipova T, Kazakevich E, Serdechnaya E, Zavyalova O, Novikova T, Riabaia I, Zhigalov S, Drozdova E, Luchkina I, Monogarova Y, Hegya D, Rodionova L, Rodionova L, Nevzorova V, Soldatova I, Lusanova O, Arandjelovic A, Toncev D, Milanov M, Sekularac N, Zdravkovic M, Hinic S, Dimkovic S, Acimovic T, Saric J, Polovina M, Potpara T, Vujisic-Tesic B, Nedeljkovic M, Zlatar M, Asanin M, Vasic V, Popovic Z, Djikic D, Sipic M, Peric V, Dejanovic B, Milosevic N, Stevanovic A, Andric A, Pencic B, Pavlovic-Kleut M, Celic V, Pavlovic M, Petrovic M, Vuleta M, Petrovic N, Simovic S, Savovic Z, Milanov S, Davidovic G, Iric-Cupic V, Simonovic D, Stojanovic M, Stojanovic S, Mitic V, Ilic V, Petrovic D, Deljanin Ilic M, Ilic S, Stoickov V, Markovic S, Kovacevic S, García Fernandez A, Perez Cabeza A, Anguita M, Tercedor Sanchez L, Mau E, Loayssa J, Ayarra M, Carpintero M, Roldán Rabadan I, Leal M, Gil Ortega M, Tello Montoliu A, Orenes Piñero E, Manzano Fernández S, Marín F, Romero Aniorte A, Veliz Martínez A, Quintana Giner M, Ballesteros G, Palacio M, Alcalde O, García-Bolao I, Bertomeu Gonzalez V, Otero-Raviña F, García Seara J, Gonzalez Juanatey J, Dayal N, Maziarski P, Gentil-Baron P, Shah D, Koç M, Onrat E, Dural IE, Yilmaz K, Özin B, Tan Kurklu S, Atmaca Y, Canpolat U, Tokgozoglu L, Dolu AK, Demirtas B, Sahin D, Ozcan Celebi O, Diker E, Gagirci G, Turk UO, Ari H, Polat N, Toprak N, Sucu M, Akin Serdar O, Taha Alper A, Kepez A, Yuksel Y, Uzunselvi A, Yuksel S, Sahin M, Kayapinar O, Ozcan T, Kaya H, Yilmaz MB, Kutlu M, Demir M, Gibbs C, Kaminskiene S, Bryce M, Skinner A, Belcher G, Hunt J, Stancombe L, Holbrook B, Peters C, Tettersell S, Shantsila A, Lane D, Senoo K, Proietti M, Russell K, Domingos P, Hussain S, Partridge J, Haynes R, Bahadur S, Brown R, McMahon S, Y H Lip G, McDonald J, Balachandran K, Singh R, Garg S, Desai H, Davies K, Goddard W, Galasko G, Rahman I, Chua Y, Payne O, Preston S, Brennan O, Pedley L, Whiteside C, Dickinson C, Brown J, Jones K, Benham L, Brady R, Buchanan L, Ashton A, Crowther H, Fairlamb H, Thornthwaite S, Relph C, McSkeane A, Poultney U, Kelsall N, Rice P, Wilson T, Wrigley M, Kaba R, Patel T, Young E, Law J, Runnett C, Thomas H, McKie H, Fuller J, Pick S, Sharp A, Hunt A, Thorpe K, Hardman C, Cusack E, Adams L, Hough M, Keenan S, Bowring A, Watts J, Zaman J, Goffin K, Nutt H, Beerachee Y, Featherstone J, Mills C, Pearson J, Stephenson L, Grant S, Wilson A, Hawksworth C, Alam I, Robinson M, Ryan S, Egdell R, Gibson E, Holland M, Leonard D, Mishra B, Ahmad S, Randall H, Hill J, Reid L, George M, McKinley S, Brockway L, Milligan W, Sobolewska J, Muir J, Tuckis L, Winstanley L, Jacob P, Kaye S, Morby L, Jan A, Sewell T, Boos C, Wadams B, Cope C, Jefferey P, Andrews N, Getty A, Suttling A, Turner C, Hudson K, Austin R, Howe S, Iqbal R, Gandhi N, Brophy K, Mirza P, Willard E, Collins S, Ndlovu N, Subkovas E, Karthikeyan V, Waggett L, Wood A, Bolger A, Stockport J, Evans L, Harman E, Starling J, Williams L, Saul V, Sinha M, Bell L, Tudgay S, Kemp S, Brown J, Frost L, Ingram T, Loughlin A, Adams C, Adams M, Hurford F, Owen C, Miller C, Donaldson D, Tivenan H, Button H, Nasser A, Jhagra O, Stidolph B, Brown C, Livingstone C, Duffy M, Madgwick P, Roberts P, Greenwood E, Fletcher L, Beveridge M, Earles S, McKenzie D, Beacock D, Dayer M, Seddon M, Greenwell D, Luxton F, Venn F, Mills H, Rewbury J, James K, Roberts K, Tonks L, Felmeden D, Taggu W, Summerhayes A, Hughes D, Sutton J, Felmeden L, Khan M, Walker E, Norris L, O’Donohoe L, Mozid A, Dymond H, Lloyd-Jones H, Saunders G, Simmons D, Coles D, Cotterill D, Beech S, Kidd S, Wrigley B, Petkar S, Smallwood A, Jones R, Radford E, Milgate S, Metherell S, Cottam V, Buckley C, Broadley A, Wood D, Allison J, Rennie K, Balian L, Howard L, Pippard L, Board S, Pitt-Kerby T. Epidemiology and impact of frailty in patients with atrial fibrillation in Europe. Age Ageing 2022; 51:6670566. [PMID: 35997262 DOI: 10.1093/ageing/afac192] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/08/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. OBJECTIVES We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. METHODS A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. RESULTS Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. CONCLUSIONS In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.
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Affiliation(s)
- Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Translational and Precision Medicine, Sapienza - University of Rome, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Stephanie L Harrison
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, University of Murcia, CIBER-CV, Murcia, Spain
| | - Michael Näbauer
- Department of Cardiology, Ludwig-Maximilians-University, Munich, Germany
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia.,Clinical Center of Serbia, Belgrade, Serbia
| | - Gheorghe-Andrei Dan
- University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Matteo Cesari
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Tenge T, Santer D, Schlieper D, Schallenburger M, Schwartz J, Meier S, Akhyari P, Pfister O, Walter S, Eckstein S, Eckstein F, Siegemund M, Gaertner J, Neukirchen M. Inpatient Specialist Palliative Care in Patients With Left Ventricular Assist Devices (LVAD): A Retrospective Case Series. Front Cardiovasc Med 2022; 9:879378. [PMID: 35845069 PMCID: PMC9280978 DOI: 10.3389/fcvm.2022.879378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRepeat hospitalizations, complications, and psychosocial burdens are common in patients with left ventricular assist devices (LVAD). Specialist palliative care (sPC) involvement supports patients during decision-making until end-of-life. In the United States, guidelines recommend early specialist palliative care (esPC) involvement prior to implantation. Yet, data about sPC and esPC involvement in Europe are scarce.Materials and MethodsThis is a retrospective descriptive study of deceased LVAD patients who had received sPC during their LVAD-related admissions to two university hospitals in Duesseldorf, Germany and Basel, Switzerland from 2010 to 2021. The main objectives were to assess: To which extent have LVAD patients received sPC, how early is sPC involved? What are the characteristics of those, how did sPC take place and what are key challenges in end-of-life care?ResultsIn total, 288 patients were implanted with a LVAD, including 31 who received sPC (11%). Twenty-two deceased LVAD patients (19 male) with sPC were included. Mean patient age at the time of implantation was 67 (range 49–79) years. Thirteen patients (59%) received LVAD as destination therapy, eight patients (36%) were implanted as bridge to transplantation (BTT), and one as an emergency LVAD after cardiogenic shock (5%). None of the eight BTT patients received a heart transplantation before dying. Most (n = 13) patients lived with their family and mean Eastern Cooperative Oncology Group (ECOG) performance status was three. Mean time between LVAD implantation and first sPC contact was 1.71 years, with a range of first sPC contact from 49 days prior to implantation to more than 6 years after. Two patients received esPC before implantation. In Duesseldorf, mean time between first sPC contact and in-hospital death was 10.2 (1–42) days. In Basel, patients died 16 (0.7–44) months after first sPC contact, only one died on the external sPC unit. Based on thorough examination of two case reports, we describe key challenges of sPC in LVAD patients including the necessity for sPC expertise, ethical and communicative issues as well as the available resources in this setting.ConclusionDespite unequivocal recommendations for sPC in LVAD patients, the integration of sPC for these patients is yet not well established.
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Affiliation(s)
- Theresa Tenge
- Department of Anesthesiology, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
| | - David Santer
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Schlieper
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
| | - Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
| | - Jacqueline Schwartz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
| | - Stefan Meier
- Department of Anesthesiology, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
| | - Payam Akhyari
- Department of Cardiovascular Surgery, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
| | - Otmar Pfister
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Silke Walter
- Department of Palliative Care, University Hospital Basel, Basel, Switzerland
- Department of Practice Development Nursing, University Hospital Basel, Basel, Switzerland
| | - Sandra Eckstein
- Department of Palliative Care, University Hospital Basel, Basel, Switzerland
- *Correspondence: Sandra Eckstein,
| | - Friedrich Eckstein
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Jan Gaertner
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Palliative Care Center Hildegard, Basel, Switzerland
| | - Martin Neukirchen
- Department of Anesthesiology, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich Heine University, Duesseldorf, Germany
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Gaertner J, Fusi-Schmidhauser T. Dexmedetomidine: a magic bullet on its way into palliative care-a narrative review and practice recommendations. Ann Palliat Med 2022; 11:1491-1504. [PMID: 35400162 DOI: 10.21037/apm-21-1989] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 03/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE Dexmedetomidine is a potent adrenergic alpha-2 receptor agonist. It was first approved for sedation for mechanically ventilated patients. Being a sedative medication that is not associated with respiratory depression and holding analgesic properties fosters the interest for this drug in the palliative care field. The primary objectives of this review were to identify the key indications for the real-world use of dexmedetomidine in palliative care and other disciplines. METHODS A narrative review after extensive PubMed search was performed from 1950 to present on. KEY AND CONTENT AND FINDINGS (I) Current dexmedetomidine use. There is a growing body of evidence that dexmedetomidine may reduce the incidence and severity of delirium, reduce opioid-consumption and postoperative nausea in intensive care settings. It is also used to facilitate withdrawal from different substances (alcohol, opioids, heroin). Concerning safety aspects of the drug, some studies reported an increased rate of serious cardiovascular events in patients with pre-existing heart conditions due to bradycardia and arterial hypo- and hypertension. Since the drug has a main hepatic metabolism, dose reduction is mandatory in patients with hepatic impairment. (II) Dexmedetomidine and palliative care. There have been sporadic case reports about the successful use of dexmedetomidine in palliative care. Indications for symptom control included sedation for hyperactive delirium, cancer pain, opioid-induced-hyperalgesia, dystonia, cough, vomiting, shivering and dyspnea. It is mainly applied via the intravenous (i.v.), subcutaneous, but also nasal and, buccal routes. Admixture ("syringe-driver") studies showed that dexmedetomidine is compatible with morphine, hydromorphone, hyoscine and haloperidol. In 2021, a first prospective cohort study became available. Here, the authors reported promising result for dexmedetomidine use in hyperactive terminal delirium for reducing delirium intensity and agitation. Especially the unique "conscious sedation" or "awake sedation" that allows patients to arouse easily under sedation and report comfort or distress was discussed by the authors. CONCLUSIONS In this review, we present the main findings for dexmedetomidine from palliative care settings and other disciplines. The potential benefits and criticalities of the drug are discussed and practical recommendations for its use are provided.
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Affiliation(s)
- Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland; Faculty of Medicine, University Basel, Basel, Switzerland
| | - Tanja Fusi-Schmidhauser
- Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland IOSI-EOC, Lugano, Switzerland
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10
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He L, Pi Y, Li Y, Wu Y, Jiang J, Rong X, Cai J, Yue Z, Cheng J, Li H, Chua MLK, Simone CB, Aronow WS, Lattanzi S, Palmer JD, Gaertner J, Glass J, Chen P, Tang Y. Efficacy and safety of apatinib in radiation-induced brain injury among head and neck cancer: an open-label, single-arm, phase 2 study. Int J Radiat Oncol Biol Phys 2022; 113:796-804. [PMID: 35378217 DOI: 10.1016/j.ijrobp.2022.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of radiation-induced brain injury (RI) caused by radiotherapy for head and neck cancer is challenging. Antiangiogenic therapy is a promising treatment. Apatinib is an oral tyrosine kinase inhibitor (TKI) that selectively inhibits vascular endothelial growth factor receptor (VEGFR) 2. We aimed to assess the efficacy and safety of apatinib in patients with RI. PATIENTS AND METHODS In this phase 2, open-label, single-arm, prospective study, we recruited patients aged 35-80 years with prior radiotherapy history for head and neck cancer who had newly diagnosed RI at the Sun Yat-sen Memorial Hospital, China. Apatinib was administered at a dosage of 250 mg once daily orally for 4 weeks. A Simon's mini-max two-stage design was performed. The primary outcome was the proportion of patients with an overall clinical efficacy defined as radiographic response ≥ 25% reduction in baseline brain edema volume on magnetic resonance (MR) fluid attenuated inversion recovery (FLAIR) images at week 4. Secondary endpoints were overall improvement rate of brain necrosis, neurological function, and safety. RESULTS We screened 37 patients, 36 of whom were enrolled between October 17, 2019 and August 3, 2020. At the cutoff date, 36 patients were assessed for efficacy and safety (19 to stage 1 and 17 to stage 2). Of the 36 patients evaluated for overall clinical efficacy, 22 patients (61.1%; 95%CI 43.5-76.9%) achieved the primary endpoint at week 4. Among the 31 patients with brain necrosis lesions, 19 patients (61.3%; 95%CI 42.2%-78.2%) showed improvement of brain necrosis. The most common grade 1 to 2 adverse events were hand-foot syndrome, fatigue and hypertension There were no treatment-related grade 4-5 toxicities. CONCLUSION Oral apatinib shows promising efficacy and is well-tolerated in patients with RI. Further randomized controlled studies are warranted. TRIAL REGISTRATION ClinicalTrials.gov (ID: NCT04152681).
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Affiliation(s)
- Lei He
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yaxuan Pi
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Li
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Wu
- Department of Biostatistics, Southern Medical University, Guangzhou, China
| | - Jingru Jiang
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinhua Cai
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zongwei Yue
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jinping Cheng
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Honghong Li
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Melvin Lee Kiang Chua
- Division of Radiation Oncology and Medical Sciences, National Cancer Centre Singapore, Singapore; Oncology Academic Programme, Duke-NUS Medical School, Singapore
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wilbert S Aronow
- New York Medical College/Westchester Medical Center, Valhalla, NY, USA
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Joshua D Palmer
- Departments of Radiation Oncology and Neurosurgery, The James Cancer Center at The Ohio State University, Columbus, OH, USA
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland, University of Basel, Switzerland
| | - Jon Glass
- Departments of Neurology and Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Pingyan Chen
- Department of Biostatistics, Southern Medical University, Guangzhou, China
| | - Yamei Tang
- Department of Neurology,Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China; Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.
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11
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van der Steen JT, Azizi B, Nakanishi M, Shinan‐Altman S, Mehr DR, Radbruch L, Gaertner J, Werner P, Achterberg WP, Tilburgs B, Smaling HJA. Cross‐cultural acceptability of interventions at the end of life in dementia: Video vignette study design and pilot evaluation (ERC CONT‐END WP1). Alzheimers Dement 2020. [DOI: 10.1002/alz.041542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jenny T van der Steen
- Radboud University Medical Center Nijmegen Netherlands
- Leiden University Medical Center Leiden Netherlands
| | - Bahar Azizi
- Leiden University Medical Center Leiden Netherlands
| | - Miharu Nakanishi
- Tokyo Metropolitan Institute of Medical Science Setagaya‐ku Japan
| | | | - David R Mehr
- University of Missouri, Columbia Columbia MO USA
| | | | - Jan Gaertner
- Palliative Care Center Hildegard Basel Switzerland
| | | | | | - Bram Tilburgs
- Radboud University Medical Center Nijmegen Netherlands
- Leiden University Medical Center Leiden Netherlands
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12
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Siemens W, Boehlke C, Bennett MI, Offner K, Becker G, Gaertner J. Transcutaneous electrical nerve stimulation for advanced cancer pain inpatients in specialist palliative care-a blinded, randomized, sham-controlled pilot cross-over trial. Support Care Cancer 2020; 28:5323-5333. [PMID: 32128614 PMCID: PMC7547037 DOI: 10.1007/s00520-020-05370-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/19/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE Transcutaneous electrical nerve stimulation (TENS) is a treatment option for cancer pain, but the evidence is inconclusive. We aimed to evaluate the efficacy and safety of TENS. METHODS A blinded, randomized, sham-controlled pilot cross-over trial (NCT02655289) was conducted on an inpatient specialist palliative care ward. We included adult inpatients with cancer pain ≥ 3 on an 11-point numerical rating scale (NRS). Intensity-modulated high TENS (IMT) was compared with placebo TENS (PBT). Patients used both modes according to their preferred application scheme during 24 h with a 24-h washout phase. The primary outcome was change in average pain intensity on the NRS during the preceding 24 h. Responders were patients with at least a "slight improvement." RESULTS Of 632 patients screened, 25 were randomized (sequence IMT-PBT = 13 and PBT-IMT = 12). Finally, 11 patients in IMT-PBT and 9 in PBT-IMT completed the study (N = 20). The primary outcome did not differ between groups (IMT minus PBT: - 0.2, 95% confidence interval - 0.9 to 0.6). However, responder rates were higher in IMT (17/20 [85%] vs. 10/20 [50%], p = 0.0428). Two patients experienced an uncomfortable feeling caused by the current, one after IMT and one after PBT. Seven patients (35%) desired a TENS prescription. Women and patients with incident pain were most likely to benefit from TENS. CONCLUSION TENS was safe, but IMT was unlikely to offer more analgesic effects than PBT. Even though many patients desired a TENS prescription, 50% still reported at least "slight pain relief" from PBT. Differences for gender and incident pain aspects demand future trials.
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Affiliation(s)
- Waldemar Siemens
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany.
| | - Christopher Boehlke
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences (LIHS), School of Medicine, University of Leeds, Leeds, UK
| | - Klaus Offner
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Jan Gaertner
- Center for Palliative Care Hildegard, Basel, Switzerland
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13
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Siemens W, Schönsteiner SS, Orellana-Rios CL, Schaekel U, Kessler J, Eschbach C, Viehrig M, Mayer-Steinacker R, Becker G, Gaertner J. Severe symptoms and very low quality-of-life among outpatients newly diagnosed with advanced cancer: data from a multicenter cohort study. Support Care Cancer 2020; 28:5547-5555. [PMID: 32185557 PMCID: PMC7547028 DOI: 10.1007/s00520-020-05388-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study was to identify symptoms of severe intensity or very low scores for quality of life (QoL) domains in newly diagnosed outpatients with advanced cancer. METHODS This multicenter cohort study from a state-wide palliative care network included adult outpatients with advanced cancer diagnosed within the preceding 8 weeks from four comprehensive cancer centers (DRKS00006162, registered on 19 May 2014). We used the Palliative Outcome Scale (POS), Hospital Anxiety and Depression Scale, and European Organization for Research and Treatment of Cancer QoL Questionnaire-C30. For each questionnaire, cut-off scores defined symptoms and QoL domains that were considered "severe" or "very low." RESULTS Of 3155 patients screened, 481/592 (81.3%) were analyzed (mean age 62.4; women n = 245, 50.9%). We identified 324/481 (67.4%) patients experiencing at least one severe symptom or a very low QoL domain (median 2; range 0 to 16). Role functioning (n = 180, 37.4%), fatigue (n = 162, 33.7%), and social functioning (n = 126, 26.2%) were most commonly affected. QoL was very low in 89 patients (18.5%). Women experienced more anxiety symptoms, fatigue, and had lower POS scores. Patients often mentioned physical symptoms and fears of adverse events resulting from disease-modifying therapies (e.g., chemotherapy) as most relevant problems. CONCLUSIONS Already within the first 8 weeks after diagnosis, the majority of patients reported at least one severe symptom or a very low QoL domain. Gender differences were evident. The findings illustrate the value of early routine assessment of patient burden and the development of multi-professional and interdisciplinary palliative care.
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Affiliation(s)
- Waldemar Siemens
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany.
| | | | - Claudia Lorena Orellana-Rios
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Ulrike Schaekel
- Internal Medicine V, Hematology/Oncology/Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jens Kessler
- Department of Anesthesiology, Center of Pain Therapy and Palliative Care Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Corinna Eschbach
- Department of Thoracic Oncology, Member of the German Centre for Lung Research (DZL), University Hospital Heidelberg and Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany
| | - Marén Viehrig
- Department of Radiooncology, Palliative Care Unit, University Hospital of Tübingen, Tuebingen, Germany
| | | | - Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Robert-Koch-Str 3, 79106, Freiburg, Germany
| | - Jan Gaertner
- Center for Palliative Care Hildegard, Basel, Switzerland
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Gaertner J, Simone II CB, Lim F. Life-long-learning: the importance of Specialist Palliative Care Teams staying informed with knowledge from other disciplines. Ann Palliat Med 2020; 9:1290-1291. [DOI: 10.21037/apm.2020.03.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/27/2020] [Indexed: 11/06/2022]
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15
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Nestle U, Adebahr S, Kaier K, Gkika E, Schimek-Jasch T, Hechtner M, Momm F, Gaertner J, Becker G, Grosu AL. Quality of life after pulmonary stereotactic fractionated radiotherapy (SBRT): Results of the phase II STRIPE trial. Radiother Oncol 2020; 148:82-88. [PMID: 32339780 DOI: 10.1016/j.radonc.2020.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/21/2020] [Accepted: 03/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Preserving health related quality of life (HRQOL) plays an important role in considering stereotactic body fractionated radiotherapy (SBRT). The prospective monocenter phase II STRIPE trial investigated long-term HRQOL after SBRT, efficacy and toxicity. MATERIALS AND METHODS Patients with ≤2 pulmonary lesions ≤5 cm were treated with 4DPET/CT-based SBRT (3 × 12.5 Gy or risk-adapted 5 × 7 Gy, to 60% isodose). Follow up (FU) was performed 2 and 7 weeks after SBRT, then 3-monthly for 2 years with assessment of response (primary endpoint: 2-year cumulative incidence of local progression (LP); secondary endpoints: local progression free survival (LPFS), overall survival (OS) and toxicity (CTCAE)). Impact of predefined patient and treatment related factors on HRQOL (EORTC QLQ-C30 and EORTC QLQ-LC13) was evaluated. RESULTS Between 02/2011 and 11/2014, 100 patients were given SBRT for 56 NSCLC and 44 pulmonary metastases (M1). Long-term FU overall revealed stable Quality of Life (QoL)/Global health status (GHS), functions-scores and symptoms. For QoL/GHS, patients with low (<median) initial QoL/GHS-Score revealed significantly stronger improvement than those with good QoL/GHS-scores (p < 0.001). Probability for LP, LPFS and OS 2 years after SBRT was 8.1% (NSCLC: 7.3%, M1:9.2%), 53.3% (NSCLC: 50.7%, M1: 56.0%) and 62.2% (NSCLC: 57.2%, M1: 68.4%). ≥G3-Toxicity was <4%, but ≥G3 dyspnea was 6% at baseline and 14.5% 2 years after SBRT. CONCLUSIONS These prospective data on representative pulmonary SBRT patients confirm stable preservation of HRQOL after SBRT and demonstrate a QoL/GHS-benefit for patients with low initial QoL/GHS-scores, the regimen of 3 × 12.5 Gy SBRT being efficient and well tolerated. This result may inform shared decision making when discussing SBRT for frail patients.
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Affiliation(s)
- Ursula Nestle
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany; Department of Radiation Oncology, Kliniken Maria Hilf GmbH Mönchengladbach, Germany
| | - Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Marlene Hechtner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Germany; German Cancer Consortium (DKTK), Partner Site Mainz, Germany
| | - Felix Momm
- Department of Radio-oncology, Ortenau Klinikum Offenburg-Kehl, Germany
| | - Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland
| | - Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
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16
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Adebahr S, Nestle U, Gkika E, Kaier K, Schimek-Jasch T, Hechtner M, Momm F, Gaertner J, Becker G, Grosu A. P2.17-19 Quality of Life After Pulmonary Stereotactic Fractionated Radiotherapy: Longterm Results of the Phase II STRIPE Trial. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.1930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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17
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Gaertner J, Boehlke C, Simone CB, Hui D. Early palliative care and the opioid crisis: ten pragmatic steps towards a more rational use of opioids. Ann Palliat Med 2019; 8:490-497. [PMID: 31431028 DOI: 10.21037/apm.2019.08.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 07/31/2019] [Indexed: 11/06/2022]
Abstract
In palliative care, opioids and other controlled drugs are among the most commonly used and important medications. Opioids are associated with significant risk of dependence and misuse. In many developed countries, there is an epidemic of prescription opioid misuse and overdose deaths. Palliative care has a critical role educating patients about the safe use of opioids, providing universal screening and close monitoring, and prescribing opioids appropriately balancing the risks and benefits. This is particularly important in the era of early palliative care, when patients have much longer survival and potentially greater risk of misuse while on chronic opioid therapy. Here, we provided a critical appraisal of opioid use in the context of opioid crisis and early palliative care. We also present a pragmatic 10-step approach for the judicious use of opioids.
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Affiliation(s)
- Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland.
| | - Christopher Boehlke
- Clinic for Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX, USA
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Gaertner J, Eychmueller S, Leyhe T, Bueche D, Savaskan E, Schlögl M. Benzodiazepines and/or neuroleptics for the treatment of delirium in palliative care?-a critical appraisal of recent randomized controlled trials. Ann Palliat Med 2019; 8:504-515. [PMID: 30943743 DOI: 10.21037/apm.2019.03.06] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/17/2019] [Indexed: 11/06/2022]
Abstract
Delirium is a frequent condition in patients in a palliative care situation and most often associated with substantial burden or even danger for the persons concerned as well as caregivers and health-care-professionals. Despite the lack of randomized-controlled-trials (RCTs) benzodiazepines and neuroleptic agents are used extensively in palliative care for the pharmacological management of delirium. A focused review for RCTs assessing pharmacotherapy with benzodiazepines and neuroleptics for the treatment of delirium in patients treated in a palliative care or hospice setting published in 2017 was performed in PubMed. A narrative summary of the findings of the RCTs and practical recommendation are presented. Of 42 publications, two RCTs could be included. One trial assessed the use of lorazepam (in addition to haloperidol) in case of agitation, the other placebo or risperidone or haloperidol in delirious palliative care patients. Neither risperidone nor haloperidol were superior compared to placebo, but were associated with higher mortality and morbidity. Lorazepam (along with haloperidol) reduced agitation in patients with delirium compared to placebo (along with haloperidol), but was unable to reduce the severity and incidence of delirium. It is of importance to note that psychopharmacotherapy with antipsychotics is mainly indicated for the hyperactive form of delirium and psychotic symptoms (e.g., delusions or hallucinations) in the hyper- and hypoactive delirium. Severe agitation and aggressivity can be an indication for neuroleptics, when non-pharmacological interventions fail, whereas the use of benzodiazepines has to be limited to critical situations where neuroleptics cannot be applied and cases of delirium due to alcohol withdrawal. Both substances can aggravate, precipitate or mask delirium, result adverse events with substantial distress or unfavorable survival outcomes for the patients. Thus, they should only be used in severely symptomatic patients and the duration of the medication has to be limited in time. When delirium symptoms decay the psychopharmacotherapy has to be tapered. More important than psychopharmacotherapy, the thorough investigation and treatment of potentially reversible causes of delirium (e.g., pharmacotherapy, infection) and the routine identification of patients at risk for delirium along with prophylactic measures are essential. The recently published landmarks RCTs provide moderate evidence to adopt recommendations from other medical specialties (i.e., intensive care, geriatrics) to the field of palliative care.
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Affiliation(s)
- Jan Gaertner
- Palliative Care Center Hildegard, Basel, Switzerland.
| | | | - Thomas Leyhe
- Center of Old Age Psychiatry, Psychiatric Clinics (UPK), University of Basel, Basel, Switzerland
| | - Daniel Bueche
- Palliative Center, Cantonal Hospital, St. Gallen, Switzerland
| | - Egemen Savaskan
- Department of Geriatric Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland
| | - Mathias Schlögl
- Department of Geriatric Psychiatry, University Hospital of Psychiatry, Zurich, Switzerland; Department of Geriatrics and Aging Research, Department of Radiation Oncology, Competence Center Palliative Care, University Hospital Zurich, Zurich, Switzerland
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Adebahr S, Hechtner M, Schräder N, Schimek-Jasch T, Kaier K, Duncker-Rohr V, Gkika E, Momm F, Gaertner J, Becker G, Grosu AL, Nestle U. Early Impact of Pulmonary Fractionated Stereotactic Body Radiotherapy on Quality of Life:Benefit for Patients With Low Initial Scores (STRIPE Trial). J Thorac Oncol 2018; 14:408-419. [PMID: 30521969 DOI: 10.1016/j.jtho.2018.10.170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 09/26/2018] [Accepted: 10/31/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Quality of life (QoL) of comorbid patients with pulmonary malignancies is a key issue in considering fractionated stereotactic body radiotherapy (SBRT) indication. This study investigates the early impact of SBRT on QoL. METHODS One hundred patients with pulmonary lesions were treated with SBRT from February 2011 to December 2014 within the prospective, monocenter, phase II STRIPE trial. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core module (EORTC QLQ-C30) and the QLQ-LC13 lung cancer-specific questionnaire were used to evaluate QoL before, 2 and 7 weeks after SBRT, then every 3 months for 2 years. We report on the analysis of early changes from baseline to 7-week follow-up exam. Impact of patient- and treatment-related factors on the change in QoL was analyzed. RESULTS QoL was assessed in 97 patients; compliance was 92% and 85% at baseline and 7 weeks after SBRT, respectively. No clinically relevant changes greater than or equal to 10 in the QoL/global health status (GHS), function scores and inquired symptoms were observed. Patients with baseline QoL below the median showed clinically relevant improvement in QoL/GHS (Δ16.7 ± 25.3, p = 0.003), emotional function (Δ14.4 ± 25.4, p = 0.013), and fatigue (Δ -10.1 ± 26.5, p = 0.089) in contrast to patients with high initial scores. No changes were observed in the dichotomized subgroups of initial Karnofsky index, Charlson Comorbidity Index, age, diagnosis, and tumor localization. CONCLUSIONS In short-term follow-up, QoL is well maintained after pulmonary SBRT. Especially patients with low initial QoL/GHS scores show benefit from SBRT with respect to QoL.
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Affiliation(s)
- Sonja Adebahr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Marlene Hechtner
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; German Cancer Consortium (DKTK), Partner Site /Mainz, Germany
| | - Nele Schräder
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tanja Schimek-Jasch
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Viola Duncker-Rohr
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Radio-oncology, Ortenau Klinikum Offenburg-Gengenbach, Offenburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felix Momm
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of Radio-oncology, Ortenau Klinikum Offenburg-Gengenbach, Offenburg, Germany
| | - Jan Gaertner
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Palliative Care Center Hildegard, Basel, Switzerland
| | - Gerhild Becker
- Clinic for Palliative Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ursula Nestle
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany; Department of Radiation Oncology, Kliniken Maria Hilf GmbH Mönchengladbach, Mönchengladbach, Germany
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Jiang J, Li Y, Shen Q, Rong X, Huang X, Li H, Zhou L, Mai HQ, Zheng D, Chen MY, Xu Y, Li J, Hui X, Simone CB, Gaertner J, Argyriou AA, Chow E, Chen P, Tang Y. Effect of Pregabalin on Radiotherapy-Related Neuropathic Pain in Patients With Head and Neck Cancer: A Randomized Controlled Trial. J Clin Oncol 2018; 37:135-143. [PMID: 30457920 DOI: 10.1200/jco.18.00896] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Neuropathic pain is an unavoidable treatment-related adverse event among patients with head and neck cancer who are undergoing radiotherapy. We aimed to test the efficacy and safety of pregabalin versus placebo in the treatment of radiotherapy-related neuropathic pain. PATIENTS AND METHODS This randomized, double-blind, placebo-controlled trial was conducted in four centers in China. Eligible patients with a mean pain intensity score of 4 or more on an 11-point numeric rating scale were randomly assigned to receive either active treatment with a flexible dose of pregabalin or placebo for 16 weeks. The primary efficacy outcome was pain reduction measured on the numeric rating scale. RESULT There were 128 patients who received treatment as randomly assigned. Pain intensity reduction was 2.44 in the pregabalin arm and 1.58 in the placebo arm at week 16, yielding an adjusted mean difference of 0.87 (95% CI, 0.30 to 1.44; P = .003). In the pregabalin arm, 38 patients (59.4%) achieved at least 30% pain relief versus 21 (32.8%) in the placebo arm ( P = .006). Nineteen patients (29.7%) in the pregabalin group and five (7.8%) in the placebo group achieved 50% or greater pain relief ( P = .003). Total scores on the Profile of Mood States-Short Form, pain severity and functional interference of Brief Pain Inventory-Short Form, as well as the physiology and psychology domain of the WHO Quality of Life-BREF all were reduced significantly at week 16 in patients who received pregabalin compared with those who received placebo. There was no significant difference ( P = .29) in the incidence of experiencing at least one adverse event in the pregabalin arm (n = 35; 54.7%) versus the placebo arm (n = 29; 45.3%). CONCLUSION Patients treated with pregabalin with radiotherapy-related neuropathic pain had greater pain alleviation, better mood states, and higher quality of life compared with patients in the placebo group, with a good tolerability.
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Affiliation(s)
- Jingru Jiang
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Yi Li
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Qingyu Shen
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China.,2 Zengcheng District People's Hospital of Guangzhou, Guangzhou, People's Republic of China
| | - Xiaoming Rong
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xiaolong Huang
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Honghong Li
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Lizhi Zhou
- 3 Southern Medical University, Guangzhou, People's Republic of China
| | - Hai-Qiang Mai
- 4 Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Dong Zheng
- 5 Guangzhou Huiai Hospital, Guangzhou, People's Republic of China
| | - Ming-Yuan Chen
- 4 Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Yongteng Xu
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Jibin Li
- 4 Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Xuan Hui
- 6 Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jan Gaertner
- 8 Palliative Care Center Hildegard, Basel, Switzerland
| | | | - Edward Chow
- 10 Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Pingyan Chen
- 3 Southern Medical University, Guangzhou, People's Republic of China
| | - Yamei Tang
- 1 Sun Yat-Sen Memorial Hospital; Sun Yat-Sen University, Guangzhou, People's Republic of China
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Benze G, Nauck F, Alt-Epping B, Gianni G, Bauknecht T, Ettl J, Munte A, Kretzschmar L, Gaertner J. PROutine: a feasibility study assessing surveillance of electronic patient reported outcomes and adherence via smartphone app in advanced cancer. Ann Palliat Med 2017; 8:104-111. [PMID: 29156896 DOI: 10.21037/apm.2017.07.05] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 07/13/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND In advanced cancer, quality of life (QoL) is a major treatment goal. In order to achieve this, the identification of suffering by screening for patient-reported-outcomes (PROs, i.e., symptoms) is of utmost importance. The use of paper-pencil questionnaires is associated with significant shortcomings due to missing data, recall bias and transcription errors. Other than that, the electronic recording of PROs by mobile Health (mHealth) offers a number of advantages. The aim of this study was to test whether the routine assessment of PROs via a newly developed smartphone application (MeQoL®) is feasible. METHODS A prospective, uncontrolled, multi-center, feasibility trial was performed in adult outpatients with advanced, solid cancer. Patients under anti-cancer therapy and with regular outpatient visits were eligible. Patients daily recorded the degree of perceived distress (NCCN Distress Thermometer®), pain intensity {average and worst [numerical rating scale (NRS), 0-10]}, the number of breakthrough pain episodes (BPE) and ten questions from a modified version of the Edmonton Symptom Assessment Scale (ESAS). Weekly, five questions concerning different domains of QoL from the short-form 8 (SF-8) questionnaire were obtained. Also, patients recorded the intake of their opioid rescue medication. According to the main scope of the trial (feasibility), no primary endpoint was defined. Rather, the following main feasibility criteria were assessed: missing data, drop-out- and acceptance-rate, patient satisfaction, patients' judgement of practicability, patients' and physicians' suggestions for improvement and basic clinical and demographic data of the participating patients. The study was registered in the German Clinical Trials Register (ID: DRKS00008761). RESULTS In three German cancer centers, 40 patients {female: 28 (70%); average age, 57 years [range, 27-73 years; standard deviation (SD), 12]} were included. As three devices were lost on transport, 37 devices could be evaluated. The median investigation period per device was 99.5 days (SD, 31). Patient adherence in using the smartphone app to document their distress and symptoms was high and missing data were low: In median daily reviews were performed on 70 (SD, 29) of these days (70%) and median weekly recordings were 13 weeks (87%). Most often, patients recorded symptom intensity (89%, MIDOS) and distress (85%, NCCN thermometer). On feedback forms, patients reported a good to very good user friendliness of MeQoL® and a high motivation to use this tool again. CONCLUSIONS Even though participants were asked to record PROs rather frequently (daily), missing data were low and patient satisfaction was high. Having in mind the findings of other working groups, such routine implementation of mHealth solutions may substantially improve outcomes of cancer therapy and increase the value of trials' findings. For the individual patient, MeQoL® allows for monitoring adherence to pharmacotherapy and can facilitate patient guidance.
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Affiliation(s)
- Gesine Benze
- Department of Palliative Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Medical Center Göttingen, Göttingen, Germany
| | | | | | - Johannes Ettl
- Departement of Gynecology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Anna Munte
- Departement of Gynecology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Luisa Kretzschmar
- Department of Gynecology, Charité-University Medical Center Berlin CVK, Berlin, Germany
| | - Jan Gaertner
- Center for Palliative Care Hildegard, Basel, Switzerland.
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Gaertner J, Siemens W, Meerpohl JJ, Antes G, Meffert C, Xander C, Stock S, Mueller D, Schwarzer G, Becker G. Effect of specialist palliative care services on quality of life in adults with advanced incurable illness in hospital, hospice, or community settings: systematic review and meta-analysis. BMJ 2017; 357:j2925. [PMID: 28676557 PMCID: PMC5496011 DOI: 10.1136/bmj.j2925] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objective To assess the effect of specialist palliative care on quality of life and additional outcomes relevant to patients in those with advanced illness.Design Systematic review with meta-analysis.Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and trial registers searched up to July 2016.Eligibility criteria for selecting studies Randomised controlled trials with adult inpatients or outpatients treated in hospital, hospice, or community settings with any advanced illness. Minimum requirements for specialist palliative care included the multiprofessional team approach. Two reviewers independently screened and extracted data, assessed the risk of bias (Cochrane risk of bias tool), and evaluated the quality of evidence (GRADE tool).Data synthesis Primary outcome was quality of life with Hedges' g as standardised mean difference (SMD) and random effects model in meta-analysis. In addition, the pooled SMDs of the analyses of quality of life were re-expressed on the global health/QoL scale (item 29 and 30, respectively) of the European Organization for Research and Treatment of Cancer QLQ-C30 (0-100, high values=good quality of life, minimal clinically important difference 8.1).Results Of 3967 publications, 12 were included (10 randomised controlled trials with 2454 patients randomised, of whom 72% (n=1766) had cancer). In no trial was integration of specialist palliative care triggered according to patients' needs as identified by screening. Overall, there was a small effect in favour of specialist palliative care (SMD 0.16, 95% confidence interval 0.01 to 0.31; QLQ-C30 global health/QoL 4.1, 0.3 to 8.2; n=1218, six trials). Sensitivity analysis showed an SMD of 0.57 (-0.02 to 1.15; global health/QoL 14.6, -0.5 to 29.4; n=1385, seven trials). The effect was marginally larger for patients with cancer (0.20, 0.01 to 0.38; global health/QoL 5.1, 0.3 to 9.7; n=828, five trials) and especially for those who received specialist palliative care early (0.33, 0.05 to 0.61, global health/QoL 8.5, 1.3 to 15.6; n=388, two trials). The results for pain and other secondary outcomes were inconclusive. Some methodological problems (such as lack of blinding) reduced the strength of the evidence.Conclusions Specialist palliative care was associated with a small effect on QoL and might have most pronounced effects for patients with cancer who received such care early. It could be most effective if it is provided early and if it identifies though screening those patients with unmet needs.Systematic review registration PROSPERO CRD42015020674.
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Affiliation(s)
- Jan Gaertner
- Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
- Palliative Care Centre Hildegard, Basel, Switzerland
| | - Waldemar Siemens
- Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Joerg J Meerpohl
- Cochrane Germany, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité-U1153, Inserm/Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, 1 Place du Parvis Notre Dame, 75181 Paris Cedex 04, France
| | - Gerd Antes
- Cochrane Germany, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Cornelia Meffert
- Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Carola Xander
- Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany
| | - Dirk Mueller
- Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany
| | - Guido Schwarzer
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, Germany
| | - Gerhild Becker
- Clinic for Palliative Care, Medical Centre, University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Gaertner J, Stamer UM, Remi C, Voltz R, Bausewein C, Sabatowski R, Wirz S, Müller-Mundt G, Simon ST, Pralong A, Nauck F, Follmann M, Radbruch L, Meißner W. Metamizole/dipyrone for the relief of cancer pain: A systematic review and evidence-based recommendations for clinical practice. Palliat Med 2017; 31:26-34. [PMID: 27435604 DOI: 10.1177/0269216316655746] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Dipyrone (metamizole) is one of the most widely used non-opioid analgesics for the treatment of cancer pain. AIM Because evidence-based recommendations are not yet available, a systematic review was conducted for the German Guideline Program in Oncology to provide recommendations for the use of dipyrone in cancer pain. DESIGN First, a systematic review for clinical trials assessing dipyrone in adult patients with cancer pain was conducted. Endpoints were pain intensity, opioid-sparing effects, safety, and quality of life. DATA SOURCES The search was performed in MedLine, Embase (via Ovid), and the Cochrane Library (1948-2013) and additional hand search was conducted. Finally, recommendations were developed and agreed in a formal structured consensus process by 53 representatives of scientific medical societies and 49 experts. RESULTS Of 177 retrieved studies, 4 could be included (3 randomized controlled trials and 1 cohort study, n = 252 patients): dipyrone significantly decreased pain intensity compared to placebo, even if low doses (1.5-2 g/day) were used. Higher doses (3 × 2 g/day) were more effective than low doses (3 × 1 g/day), but equally effective as 60 mg oral morphine/day. Pain reduction of dipyrone and non-steroidal anti-inflammatory drugs did not differ significantly. Compared to placebo, non-steroidal anti-inflammatory drugs, and morphine, the incidence of adverse effects was not increased. CONCLUSION Dipyrone can be recommended for the treatment of cancer pain as an alternative to other non-opioids either alone or in combination with opioids. It can be preferred over non-steroidal anti-inflammatory drugs due to the presumably favorable side effect profile in long-term use, but comparative studies are not available for long-term use.
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Affiliation(s)
- Jan Gaertner
- 1 Clinic for Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Ulrike M Stamer
- 2 Department of Anesthesiology and Pain Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Constanze Remi
- 3 Department of Palliative Medicine, University Hospital Bonn, Germany
| | - Raymond Voltz
- 4 Department of Palliative Care, University Hospital Cologne, Cologne, Germany
| | - Claudia Bausewein
- 3 Department of Palliative Medicine, University Hospital Bonn, Germany
| | - Rainer Sabatowski
- 5 Comprehensive Pain Centre, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Stefan Wirz
- 6 Department for Anaesthesiology, Intensive Medicine, Pain/Palliative Care, GFO CURA Hospital, Bad Honnef, Germany
| | | | - Steffen T Simon
- 4 Department of Palliative Care, University Hospital Cologne, Cologne, Germany
| | - Anne Pralong
- 4 Department of Palliative Care, University Hospital Cologne, Cologne, Germany
| | - Friedemann Nauck
- 8 Department of Palliative Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Markus Follmann
- 9 Department of Guideline Development, German Cancer Society (DKG), Berlin, Germany
| | - Lukas Radbruch
- 10 Department of Palliative Medicine, University Hospital Bonn, Germany
| | - Winfried Meißner
- 11 Department of Palliative Care, Jena University Hospital, Jena, Germany
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Petersen B, Busch T, Gaertner J, Haitsma JJ, Krabbendam S, Ebsen M, Lachmann B, Kaisers UX. Complement activation contributes to ventilator-induced lung injury in rats. J Physiol Pharmacol 2016; 67:911-918. [PMID: 28195072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 12/27/2016] [Indexed: 06/06/2023]
Abstract
The complement system contributes to ventilator induced lung injury (VILI). We hypothesized that pretreatment with the C1 esterase inhibitor (C1INH) Berinert® constrains complement activation consecutively inducing improvements in arterial oxygenation and histological pulmonary damage. At baseline, male Sprague-Dawley rats underwent mechanical ventilation in a conventional mode (PIP 13 cm H2O, PEEP 3 cm H2O). In the Control group, the ventilator setting was maintained (Control, n = 15). The other animals randomly received intravenous pretreatment with either 100 units/kg of the C1-INH Berinert® (VILI-C1INH group, n = 15) or 1 ml saline solution (VILI-C group, n = 15). VILI was induced by invasive ventilation (PIP 35 cm H2O, PEEP 0 cm H2O). After two hours of mechanical ventilation, the complement component C3a remained low in the Control group (258 ± 82 ng/ml) but increased in both VILI groups (VILI-C: 1017 ± 283 ng/ml; VILIC1INH: 817 ± 293 ng/ml; P < 0.05 for both VILI groups versus Control). VILI caused a profound deterioration of arterial oxygen tension (VILI-C: 193 ± 167 mmHg; VILI/C1-INH: 154 ± 115 mmHg), whereas arterial oxygen tension remained unaltered in the Control group (569 ± 26 mmHg; P < 0.05 versus both VILI groups). Histological investigation revealed prominent overdistension and interstitial edema in both VILI groups compared to the Control group. C3a plasma level in the VILI group were inversely correlated with arterial oxygen tension (R = -0.734; P < 0.001). We conclude that in our animal model of VILI the complement system was activated in parallel with the impairment in arterial oxygenation and that pretreatment with 100 units/kg Berinert® did neither prevent systemic complement activation nor lung injury.
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Affiliation(s)
- B Petersen
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig Medical Faculty, Leipzig, Germany
| | - T Busch
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig Medical Faculty, Leipzig, Germany
| | - J Gaertner
- Department of Anesthesiology and Intensive Care Medicine, Schoen Clinics, Vogtareuth, Germany
| | - J J Haitsma
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherland
- Departments of Anesthesiology and Intensive Care, VU Medical Center, Amsterdam, The Netherlands
| | - S Krabbendam
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherland
| | - M Ebsen
- Institute of Pathology, Community Hospital, Kiel, Germany
| | - B Lachmann
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherland
- Department of Anesthesiology and Intensive Care, Charite University Medical Center, Campus Virchow Klinikum and Campus Charite-Mitte, Berlin, Germany
| | - U X Kaisers
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig Medical Faculty, Leipzig, Germany
- University Hospital, Ulm, Germany.
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Gaertner J, Maier BO, Radbruch L. Resource allocation issues concerning early palliative care. Ann Palliat Med 2016; 4:156-61. [PMID: 26231812 DOI: 10.3978/j.issn.2224-5820.2015.07.02] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 07/02/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND The concept of early palliative care (ePC) has received enormous recognition in the field of cancer care. Increasing evidence supports this approach, but outside the research arena, the implementation of sustainable clinical concepts rely on solutions for practical problems such as funding issues. Therefore, the article presented here discusses economic considerations associated with different concepts of ePC. MAIN POINTS The specialist approach: the most frequently cited ePC trials assessing examine the concurrent provision of specialist palliative care in addition to routine care. Most of this specialist palliative care has been provided by multiprofessional teams in an outpatient setting of tertiary care centers. A number of the research groups have also provided data about the resource utilizations of this approach. From this, a rough estimate of the cost of early specialist palliative care can be derived. Yet, in many parts of North-America, Europe and other regions, funding modes for such outpatient specialist palliative care is non-existent. Recent studies have pointed out that ePC for inpatients is associated with cost-savings. These cost savings are even more pronounced the earlyer specialist palliative care is integrated in the care for the patients. Strengthening of general palliative care: most institutions recommend that palliative care as an approach should be strengthened as a part of standard care. To accomplish this, different measures such as teaching of general palliative care competencies of oncology teams, routine symptom assessment or the mandatory implementation of advanced care planning in care trajectories are being promoted. Due to the heterogeneity of these approaches, cost calculations are difficult, but can be weight against cost-saving estimated associated with for example less utilization of futile diagnostic and therapeutic procedures. CONCLUSIONS Researchers, health care providers and policy makers need to distinguish the different concepts behind ePC before providing cost estimates. Detailed information is provided in this article. From our view, it is evident that neither of the two approaches (general vs. specialist) can be a one-or-the-other choice. Successful ePC will most likely rely on a joint effort of all medical disciplines and profession in close cooperation and early integration of specialist PC services. For such an approach, additional resources may be necessary, but from the public health perspective, cost-savings can also be assumed.
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Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, University Hospital Freiburg, Robert Koch Str. 3, 79106 Freiburg, Germany.
| | - Bernd-Oliver Maier
- Departement of Palliative Medicine and Oncology, St. Josefs-Hospital, 65189 Wiesbaden, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital of Bonn, 53127 Bonn, Germany; Center of Palliative Care, Malteser Hospital Seliger Gerhard Bonn/Rhein-Sieg, Bonn, Germany
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Gaertner J, Siemens W, Daveson BA, Smith M, Evans CJ, Higginson IJ, Becker G. Of apples and oranges: Lessons learned from the preparation of research protocols for systematic reviews exploring the effectiveness of Specialist Palliative Care. BMC Palliat Care 2016; 15:43. [PMID: 27091056 PMCID: PMC4836194 DOI: 10.1186/s12904-016-0110-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/21/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Agreed terminology used in systematic reviews of the effectiveness of specialist palliative care ((S)PC)) is required to ensure consistency and usability and to help guide future similar reviews and the design of clinical trials. During the preparation of protocols for two separate systematic reviews that aimed to assess the effectiveness of SPC, two international research groups collaborated to ensure a high degree of methodological consensus and clarity between reviews. During the collaboration, it became evident that close attention is needed to (i) avoid ambiguity in the definition of advanced illness, (ii) capture the specialist expertise and prerequisites for SPC interventions, and (iii) the multi-professional and multi-dimensional nature of PC. Also, (iv) the exclusion of relevant studies or (v) impracticality of meta-analyses of the obtained data must be avoided. The aim of this article is to present the core issues of the discussion to help future research groups to easily identify potential pitfalls and methodologic necessities. CORE ISSUE DISCUSSION Core issues that arose from the discussion are presented along the research questions according to the PICO process: Population (P): Authors should refer to existing definitions of PC to ensure that, even if the review aims to investigate specific patients (e.g. cancer patients), it is important to make clear that PC is applicable for all life-limiting diseases and not limited to end-of-life or cancer. Intervention (I): PC is a core responsibility of all disciplines (general PC). In contrast, SPC demands further training and expertise. Therefore, core tenets of SPC interventions are that they are (i) multi-professional and (ii) aim at the multi-dimensional nature of suffering. Outcome (O): The main goal of PC is multi-dimensional (quality of life, suffering or distress). Yet, meta-analysis may be complex to conduct due to the heterogeneity of the multi-dimensional outcomes. Therefore, the assessment of uni-dimensional measures such as pain can also provide clinically relevant information that is easier to obtain. DISCUSSION AND CONCLUSION Recommendations for future systematic reviews and clinical trials include: (i) Appraise the experience of other research groups who have produced similar systematic reviews or clinical trials. (ii) Include studies that meet the multi-professional and multi-dimensional nature of PC and the specialization requirements for SPC. (iii) Thoroughly weigh relevance and practicability of the primary outcome. Multi-dimensional tools such as quality-of-life questionnaires assess the different dimensions of suffering (the true scope of PC), but uni-dimensional measures such as pain are easier to assess in meta-analyses.
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Affiliation(s)
- Jan Gaertner
- Clinic for Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Waldemar Siemens
- Clinic for Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara A Daveson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Melinda Smith
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Catherine J Evans
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Irene J Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - Gerhild Becker
- Clinic for Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Weingärtner V, Dargatz N, Weber C, Mueller D, Stock S, Voltz R, Gaertner J. Patient reported outcomes in randomized controlled cancer trials in advanced disease: a structured literature review. Expert Rev Clin Pharmacol 2016; 9:821-9. [PMID: 26959869 DOI: 10.1586/17512433.2016.1164595] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION In advanced cancer quality of life (QoL) is the most important goal of care. It is measured by patient-reported-outcomes (PRO). This structured review evaluated how randomized controlled trials (RCTs) on anti-cancer therapy in advanced cancer reported PRO. METHODS Search was performed in MEDLINE via PubMed for RCTs with median patient survival of ≤2 years. Reporting was rated with the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. RESULTS Of 370 retrieved publications, 117 were eligible, but only 30/117 (26%) reported PRO. QoL was most frequently measured (29/30). On average, 4.4 (SD 2.5) of the 14 CONSORT items were met. CONCLUSION PRO are insufficiently reported in advanced cancer trials. Yet, this is paramount to enable an informed and patient-oriented decision making process.
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Affiliation(s)
- V Weingärtner
- a Department of Palliative Medicine, Clinical Trials Unit and Center for Integrated Oncology (CIO) Cologne/Bonn , University Hospital of Cologne , Cologne , Germany
| | - N Dargatz
- a Department of Palliative Medicine, Clinical Trials Unit and Center for Integrated Oncology (CIO) Cologne/Bonn , University Hospital of Cologne , Cologne , Germany
| | - C Weber
- b Institute of Health Economics and Clinical Epidemiology (IGKE) , University Hospital of Cologne , Cologne , Germany
| | - D Mueller
- b Institute of Health Economics and Clinical Epidemiology (IGKE) , University Hospital of Cologne , Cologne , Germany
| | - S Stock
- b Institute of Health Economics and Clinical Epidemiology (IGKE) , University Hospital of Cologne , Cologne , Germany
| | - R Voltz
- a Department of Palliative Medicine, Clinical Trials Unit and Center for Integrated Oncology (CIO) Cologne/Bonn , University Hospital of Cologne , Cologne , Germany
| | - J Gaertner
- a Department of Palliative Medicine, Clinical Trials Unit and Center for Integrated Oncology (CIO) Cologne/Bonn , University Hospital of Cologne , Cologne , Germany.,c Department of Palliative Care , University Hospital Freiburg , Freiburg , Germany.,d Competence Center Palliative Care Baden-Württemberg , University Medical Center Freiburg , Freiburg , Baden-Württemberg , Germany
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Lange S, Gaertner J, McGauran N, Schmacke N, Weingärtner V. Inconsistent conclusions on QoL outcomes from the same clinical trial. Gastric Cancer 2016; 19:318-9. [PMID: 25893264 DOI: 10.1007/s10120-015-0499-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 02/25/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Stefan Lange
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany.
| | - Jan Gaertner
- Department of Palliative Care, University Medical Center Freiburg, Freiburg, Germany
| | - Natalie McGauran
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany
| | - Nobert Schmacke
- Institute for Public Health and Nursing Research (IPP), University of Bremen, Bremen, Germany
| | - Vera Weingärtner
- Institute for Quality and Efficiency in Health Care (IQWiG), Im Mediapark 8, 50670, Cologne, Germany.,Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
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Gronwald B, Wolff M, Gaertner J, Bialas P, Niewald M, Schmitz A, Faehndrich S, Gottschling S. Breathlessness and opioid therapy: A retrospective chart analysis in 2,958 patients. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.29_suppl.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
192 Background: Breathlessness is a common and distressing symptom, which increases in many diseases as they progress and is difficult to manage. It is widely accepted that opioids are safe and effective for treating dyspnea, although no single opioid has an authorization for the treatment of breathlessness. The aims of the study were to assess prevalence rates of breathlessness as well as the treatment approaches especially with respect to opioid therapy in all patients cared by a hospital palliative care team in a university hospital over a period of five years. Methods: A systematic review of all electronically available records of patients under palliative care service from April 2010 – April 2015 was performed. Results: Breathlessness was the third most common symptom in our patient group behind fatigue and pain. Furthermore it was classified as the utmost distressing symptom of all. Many patients suffering from breathlessness were opioid-naive before contact with our palliative care team. Many of these patients were put on prolonged-release opioids together with short-acting opioids (mucosal fentanyl) as rescue medication for breathlessness. Opioid therapy was judged to be very effective by the majority of patients suffering from breathlessness however caused (cancer-related or due to a benign disease e.g. chronic obstructive pulmonary disease). Conclusions: In a large cohort of patients breathlessness is a major topic and is clearly positively influenceable by opioids. In our opinion it is longtime overdue to strive for an authorization for opioids against breathlessness.
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Affiliation(s)
- Benjamin Gronwald
- Centre of Palliative Care and Pediatric Pain, Saarland University Hospital, Homburg, Germany
| | - Michael Wolff
- Saarland University Medical Faculty, Homburg, Germany
| | - Jan Gaertner
- Department of Palliative Care, Comprehensive Cancer Center Freiburg University, Freiburg, Germany
| | - Patric Bialas
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Homburg, Germany
| | - Marcus Niewald
- Department of Radiotherapy and Radiooncology, Homburg, Germany
| | - Andrea Schmitz
- Interdisciplinary Centre for Palliative Medicine, Duesseldorf, Germany
| | - Sebastian Faehndrich
- Department of Internal Medicine V, Pulmonology, Allergology, Intensive Care Medicine, Homburg, Germany
| | - Sven Gottschling
- Centre of Palliative Care and Pediatric Pain, Saarland University Hospital, Homburg, Germany
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Siemens W, Wehrle A, Gaertner J, Henke M, Deibert P, Becker G. Implementing a home-based exercise program for patients with advanced, incurable diseases after discharge and their caregivers: lessons we have learned. BMC Res Notes 2015; 8:509. [PMID: 26419844 PMCID: PMC4588256 DOI: 10.1186/s13104-015-1523-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Palliative care (PC) patients experience loss of physical function which usually impedes mobility, autonomy and quality of life. We aimed at examining the feasibility of a home-based exercise program for patients with advanced, incurable diseases after discharge. RESULTS This was a single-arm pilot study (WHO-ICTRP: DRKS00005048). The 12-week home-based program comprised strength, balance, flexibility and endurance components. Patients with a presumed life expectancy of 6-12 months were recruited during a 6-months period on a specialized PC and a radiation therapy ward. We chose the De Morton Mobility Index as primary outcome. Secondary outcomes were quality of life, 6-min walk test and others. A total of 145 patients were screened, 103 (98%) out of 105 patients on the specialized PC ward could not be included, mostly because of a low performance status [n = 94; 90%; Eastern Cooperative Oncology Group (ECOG) >2]. The only two eligible patients declined to participate. Eleven out of 40 patients (28%) were eligible on the radiation therapy ward. However, only one patient (9%) participated but dropped out 2 days later (upcoming surgery). Distance to the hospital (n = 3; 30%) and considering additional tasks as "too much" (n = 3; 30%) were most common reasons for non-participation. CONCLUSIONS Establishing a home-based exercise program for inpatients after discharge was not feasible mainly due to non-eligibility and lack of demand. For future trials, we suggest that choosing (1) outpatients with (2) an ECOG of ≤2 and (3) an estimated survival of ≥9 months could enhance participation in home-based exercise programs.
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Affiliation(s)
- Waldemar Siemens
- Department of Palliative Care, University Medical Center Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Anja Wehrle
- Department of Internal Medicine, Institute for Exercise- and Occupational Medicine, University Medical Center Freiburg, Hugstetter Str. 49, 79106, Freiburg, Germany.
| | - Jan Gaertner
- Department of Palliative Care, University Medical Center Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Michael Henke
- Department of Radiation Oncology, University Medical Center Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Peter Deibert
- Department of Internal Medicine, Institute for Exercise- and Occupational Medicine, University Medical Center Freiburg, Hugstetter Str. 49, 79106, Freiburg, Germany.
| | - Gerhild Becker
- Department of Palliative Care, University Medical Center Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
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Gaertner J, Siemens W, Antes G, Meerpohl JJ, Xander C, Schwarzer G, Stock S, Becker G. Specialist palliative care services for adults with advanced, incurable illness in hospital, hospice, or community settings--protocol for a systematic review. Syst Rev 2015; 4:123. [PMID: 26407847 PMCID: PMC4583160 DOI: 10.1186/s13643-015-0121-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Specialist palliative care (SPC) interventions aim to relieve and prevent suffering in the physical, psychological, social, and spiritual domain. Therefore, SPC is carried out by a multi-professional team with different occupations (e.g., physician, nurse, psychologist, and social worker). Remaining skepticism concerning the need for SPC may be based on the scarcity of high-quality evaluations about the external evidence for SPC. Therefore, we will conduct a systematic review according to Cochrane standards to examine the effects of SPC for adults with advanced illness. METHODS/DESIGN The comprehensive systematic literature search will include randomized controlled trials (RCTs) and cluster RCTs. We will search the databases MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO. Patients must be adults suffering from life-limiting diseases. Proxy and caregiver outcomes will not be assessed in order to ensure a clear and well-defined research question for this review. Interventions may be in an in- or outpatient setting, e.g., consulting service, palliative care ward, and palliative outpatient clinic. In line with the multi-dimensional scope of palliative care, the primary outcome is quality of life (QoL). Key secondary outcomes are patients' symptom burden, place of death and survival, and health economic aspects. Subgroup analysis will assess results according to cancer type, age, early vs not early SPC, site of care, and setting. Analysis will be performed with the current RevMan software. We will use the Cochrane Collaboration risk of bias assessment tool. The quality of evidence will be judged according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION The available evidence will be summarized and discussed to provide a basis for decision-making among health care professionals and policy makers. For SPC, we believe that multi-professional care is of utmost importance. Therefore, single-profession interventions such as physician consultations will not be included. Based on the multi-dimensional scope of palliative care, we chose QoL as the primary outcome, despite an expected heterogeneity among the QoL outcomes. We consider unidimensional endpoints such as "pain" for the physical domain to be inadequate for capturing the true scope of (S)PC (i.e., QoL) as defined by the World Health Organization. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015020674.
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Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Waldemar Siemens
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Gerd Antes
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Joerg J Meerpohl
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Carola Xander
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Guido Schwarzer
- Institute of Medical Biometry and Informatics, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany.
| | - Gerhild Becker
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
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Gaertner J, Lutz S, Chow E, Simone CB. Integrating palliative care and oncology: towards a common understanding. Ann Palliat Med 2015; 4:3-4. [PMID: 25813413 DOI: 10.3978/j.issn.2224-5820.2015.02.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 01/27/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Jan Gaertner
- Senior Consultant, Senior Researcher, Department of Palliative Care, Comprehensive Cancer Center Freiburg University, Freiburg, Germany.
| | - Stephen Lutz
- Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH 45840, USA
| | - Edward Chow
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Charles B Simone
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Gaertner J, Weingärtner V, Lange S, Hausner E, Gerhardus A, Simon ST, Voltz R, Becker G, Schmacke N. The Role of End-of-Life Issues in the Design and Reporting of Cancer Clinical Trials: A Structured Literature Review. PLoS One 2015; 10:e0136640. [PMID: 26327232 PMCID: PMC4556677 DOI: 10.1371/journal.pone.0136640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 08/06/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) are important sources of information on the benefits and harms patients may expect from treatment options. The aim of this structured literature review by the German Institute for Quality and Efficiency in Health Care was to explore whether and how the end-of-life (EoL) situation of patients with advanced cancer is considered in RCTs investigating anti-cancer treatments. METHODS Our journal pool comprised 19 medical journals, namely five preselected key general medical journals as well as 14 specialist journals (mainly cancer) identified via a scoping search. We systematically searched these journals in MEDLINE to identify RCTs investigating anti-cancer treatments for the following four cancer types: glioblastoma, lung cancer (stage IIIb-IV), malignant melanoma (stage IV), and pancreatic cancer (search via OVID; November 2012). We selected a representative sample of 100 publications, that is, the 25 most recent publications for each cancer type. EoL was defined as a life expectancy of ≤ two years. We assessed the information provided on (1) the descriptions of the terminal stage of the disease, (2) the therapeutic goal (i.e. the intended therapeutic benefit of the intervention studied), (3) the study endpoints assessed, (4) the authors' concluding appraisal of the intervention's effects, and (5) the terminology referring to the patients' EoL situation. RESULTS Median survival was ≤ one year for each of the four cancer types. Descriptions of the terminal stage of the disease were ambiguous or lacking in 29/100 publications. One or more therapeutic goals were mentioned in 51/100 publications; these goals were patient-relevant in 38 publications (survival alone: 30/38; health-related quality of life (HRQoL) or HRQoL and survival: 6/38; symptom control or symptom control and survival: 2/38). Primary endpoints included survival (50%), surrogates (44%), and safety (3%). Patient-reported outcomes (PROs) were assessed in 36/100 RCTs. The implications of treatment-related harms for the patients were discussed in 22/100 appraisals. Terminology referring to the patients' EoL situation (e.g. "terminal") was scarce, whereas terms suggesting control of the disease (e.g. "cancer control") were common. CONCLUSIONS The EoL situation of patients with advanced cancer should be more carefully considered in clinical trials. Although the investigation and robust reporting of PROs is a prerequisite for informed decision-making in healthcare, they are rarely defined as endpoints and HRQoL is rarely mentioned as a therapeutic goal. Suggestions for improving standards for study design and reporting are presented.
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Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, University Medical Center Freiburg, Freiburg, Germany
- Palliative Care Center of Excellence for Baden-Württemberg, Baden-Württemberg, Germany
- * E-mail:
| | - Vera Weingärtner
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Stefan Lange
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Elke Hausner
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Ansgar Gerhardus
- Institute for Public Health and Nursing Research (IPP), University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Steffen T. Simon
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
- Center for Integrated Oncology (CIO) Cologne/Bonn, Cologne/Bonn, Germany
- Clinical Trials Unit (BMBF 01KN1106), University Hospital of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
- Center for Integrated Oncology (CIO) Cologne/Bonn, Cologne/Bonn, Germany
- Clinical Trials Unit (BMBF 01KN1106), University Hospital of Cologne, Cologne, Germany
| | - Gerhild Becker
- Department of Palliative Care, University Medical Center Freiburg, Freiburg, Germany
- Palliative Care Center of Excellence for Baden-Württemberg, Baden-Württemberg, Germany
| | - Norbert Schmacke
- Institute for Public Health and Nursing Research (IPP), University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
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Gaertner J, Lutz S, Chow E. Early palliative care: philosophy vs. reality. Ann Palliat Med 2015; 4:87-88. [PMID: 26231805 DOI: 10.3978/j.issn.2224-5820.2015.07.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/15/2015] [Indexed: 06/04/2023]
Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, Comprehensive Cancer Center Freiburg University, Freiburg, Germany.
| | - Stephen Lutz
- Department of Radiation Oncology, Blanchard Valley Regional Cancer Center, Findlay, OH, USA.
| | - Edward Chow
- Department of Radiation Oncology, University of Toronto, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Meffert C, Gaertner J, Seibel K, Jors K, Bardenheuer H, Buchheidt D, Mayer-Steinacker R, Viehrig M, Paul C, Stock S, Xander C, Becker G. Early Palliative Care-Health services research and implementation of sustainable changes: the study protocol of the EVI project. BMC Cancer 2015; 15:443. [PMID: 26022223 PMCID: PMC4448282 DOI: 10.1186/s12885-015-1453-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 05/20/2015] [Indexed: 11/13/2022] Open
Abstract
Background International medical organizations such as the American Society of Medical Oncology recommend early palliative care as the “gold standard” for palliative care in patients with advanced cancer. Nevertheless, even in Comprehensive Cancer Centers, early palliative care is not yet routine practice. The main goal of the EVI project is to evaluate whether early palliative care can be implemented—in the sense of “putting evidence into practice”—into the everyday clinical practice of Comprehensive Cancer Centers. In addition, we are interested in (1) describing the type of support that patients would like from palliative care, (2) gaining information about the effect of palliative care on patients’ quality of life, and (3) understanding the economic burden of palliative care on patients and their families. Methods/design The EVI project is a multi-center, prospective cohort study with a sequential control group design. The study is a project of the Palliative Care Center of Excellence (KOMPACT) in Baden-Württemberg, Germany, which was recently established to combine the expertise of five academic, specialist palliative care departments. The study is divided into two phases: preliminary phase (months 1–9) and main study phase (months 10–18). In each of all five participating academic Comprehensive Cancer Centers, an experienced palliative care physician will be hired for 18 months. During the preliminary phase, the physician will be allowed time to establish the necessary structures for early palliative care within the Comprehensive Cancer Center. In the main study phase, patients with metastatic cancer will be offered a consultation with the palliative care physician within eight weeks of diagnosis. After the initial consultation, follow-up consultations will be offered as needed. The study is built upon a convergent parallel design. In the quantitative arm, patients will be surveyed in both the preliminary and main study phase at three points in time (baseline, 12 weeks, 24 weeks). Standardized questionnaires will be used to measure patients’ quality of life, symptom burden and mood. Using interviews with palliative care physicians, oncologists, department heads, patients and their caregivers, the qualitative arm will explore (1) what factors encourage and hinder the early integration of palliative care into standard oncology care, (2) what support patients and their caregivers would like from palliative care, and (3) what effect palliative care has on the economic disease burden of patients and their families. Discussion The study proposed is meant to serve as a catalyzer. Local palliative care teams should be put in position to routinely cooperate with the primary treating department at their respective cancer center. The long-term goal of this project is to create sustainable improvements in the care of patients with incurable cancer. Trial registration DRKS00006162; date of registration: 19/05/2014
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Affiliation(s)
- Cornelia Meffert
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany. .,Department of Palliative Care, Palliative Care Research Group, University Medical Center Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany.
| | - Jan Gaertner
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany.,Palliative Care Center of Excellence for Baden-Wuerttemberg, Baden-Wuerttemberg, Germany
| | - Katharina Seibel
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany
| | - Karin Jors
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany
| | - Hubert Bardenheuer
- Palliative Care Center of Excellence for Baden-Wuerttemberg, Baden-Wuerttemberg, Germany.,Department of Anesthesiology, Comprehensive Cancer Center, University Medical Center Heidelberg, Heidelberg, Germany
| | - Dieter Buchheidt
- Palliative Care Center of Excellence for Baden-Wuerttemberg, Baden-Wuerttemberg, Germany.,Department of Hematology and Oncology, Comprehensive Cancer Center, Mannheim University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Regine Mayer-Steinacker
- Palliative Care Center of Excellence for Baden-Wuerttemberg, Baden-Wuerttemberg, Germany.,Department of Hematology and Oncology, Comprehensive Cancer Center, University Medical Center Ulm, Ulm, Germany
| | - Marén Viehrig
- Palliative Care Center of Excellence for Baden-Wuerttemberg, Baden-Wuerttemberg, Germany.,Department of Radiation Oncology, Comprehensive Cancer Center, University Medical Center Tuebingen, Tuebingen, Germany
| | | | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, University Clinic of Cologne (AöR), Cologne, Germany
| | - Carola Xander
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany.,Palliative Care Center of Excellence for Baden-Wuerttemberg, Baden-Wuerttemberg, Germany
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Abstract
INTRODUCTION Opioid-induced constipation (OIC) is one of the most frequent and burdening adverse events (AE) of opioid therapy. This systematic review aimed to evaluate efficacy and safety of drugs in randomized controlled trials (RCTs) with adult OIC patients. AREAS COVERED Efficacy assessment focused on objective outcome measures (OOMs): bowel movement (BM) frequency, BM within 4 h and time to first BM. Twenty-one studies examining seven drugs were identified. Methylnaltrexone showed improvements in all three OOMs. RCTs in naloxone and alvimopan tended to be effective for BM frequency measures. Naloxegol (≥ 12.5 mg) improved all OOMs. Though effectiveness of lubiprostone was demonstrated for all OOMs, group differences were small to moderate. CB-5945 and prucalopride tended to increase BM frequency, especially for 0.1 mg twice daily and 4 mg daily, respectively. Besides nausea and diarrhea, abdominal pain was the most frequent AE for all drugs (risk ratio, range: 1.52 - 5.06) except for alvimopan. Treatment-related serious AEs were slightly higher for alvimopan (cardiac events) and prucalopride (severe abdominal pain, headache). Pain scores for placebo and intervention groups were similar for all drugs. EXPERT OPINION Finding a consensus definition and inclusion criteria for OIC plus a rational balance between efficacy and AEs of drugs remain future challenges.
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Affiliation(s)
- Waldemar Siemens
- University Medical Center, Department of Palliative Care , Freiburg , Germany
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Voltz R, Kamps R, Greinwald R, Hellmich M, Hamacher S, Becker G, Kuhr K, Gaertner J. Silent night: retrospective database study assessing possibility of "weekend effect" in palliative care. BMJ 2014; 349:g7370. [PMID: 25515670 PMCID: PMC4267701 DOI: 10.1136/bmj.g7370] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the mortality of patients in a palliative care unit on working days with that on weekends and public holidays. DESIGN Retrospective database study. SETTING Palliative care unit in Germany. POPULATION All admissions to palliative care unit between 1 January 1997 and 31 December 2008. MAIN OUTCOME MEASURE The impact of day type (working days or weekends and public holidays) on mortality was analysed using Poisson regression models. RESULTS A total of 2565 admitted patients and 1325 deaths were recorded. Of the deaths, 448 (33.8%) occurred on weekends and public holidays. The mortality rate on weekends and public holidays was 18% higher than that on working days (mortality rate ratio 1.18, 95% confidence interval 1.05 to 1.32; P=0.005). CONCLUSION Patients in the palliative care unit were at higher risk of dying on weekends and public holidays. In the absence of a prospective study, the exact reasons for this correlation are unclear.
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Affiliation(s)
- Raymond Voltz
- Department of Palliative Care, University Hospital Cologne, Cologne, Germany
| | - Robert Kamps
- Department of Palliative Care, Medical Clinic of St Katharinen Hospital, Frechen, Germany
| | - Ralf Greinwald
- Department of Palliative Care, University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Gerhild Becker
- Department of Palliative Care, University Hospital Freiburg, 79106 Freiburg, Germany Competence Center Palliative Care, Baden-Württemberg, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Jan Gaertner
- Department of Palliative Care, University Hospital Freiburg, 79106 Freiburg, Germany Competence Center Palliative Care, Baden-Württemberg, Germany
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Jors K, Adami S, Xander C, Meffert C, Gaertner J, Bardenheuer H, Buchheidt D, Mayer-Steinacker R, Viehrig M, George W, Becker G. Dying in cancer centers: do the circumstances allow for a dignified death? Cancer 2014; 120:3254-60. [PMID: 25200536 DOI: 10.1002/cncr.28702] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior research has shown that hospitals are often ill-prepared to provide care for dying patients. This study assessed whether the circumstances for dying on cancer center wards allow for a dignified death. METHODS In this cross-sectional study, the authors surveyed physicians and nurses in 16 hospitals belonging to 10 cancer centers in Baden-Wuerttemberg, Germany. A revised questionnaire from a previous study was used, addressing the following topics regarding end-of-life care: structural conditions (ie, rooms, staff), education/training, working environment, family/caregivers, medical treatment, communication with patients, and dignified death. RESULTS In total, 1131 surveys (response rate = 50%) were returned. Half of the participants indicated that they rarely have enough time to care for dying patients, and 55% found the rooms available for dying patients unsatisfactory. Only 19% of respondents felt that they had been well-prepared to care for the dying (physicians = 6%). Palliative care staff reported much better conditions for the dying than staff from other wards (95% of palliative care staff indicated that patients die in dignity on their ward). Generally, physicians perceived the circumstances much more positively than nurses, especially regarding communication and life-prolonging measures. Overall, 57% of respondents believed that patients could die with dignity on their ward. CONCLUSIONS Only about half of the respondents perceived that a dignified death is possible on their ward. We recommend that cancer centers invest more in staffing, adequate rooms for dying patients, training in end-of-life care, advance-care planning standards, and the early integration of specialist palliative care services.
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Affiliation(s)
- Karin Jors
- Department of Palliative Care, Comprehensive Cancer Center, University Medical Center Freiburg, Freiburg, Germany
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Gaertner J, Becker G. Patients with advanced disease: the value of patient reported outcomes. Oncol Res Treat 2014; 37:7-8. [PMID: 24613902 DOI: 10.1159/000358498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/10/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, University Medical Center Freiburg, Freiburg i.Br., Germany
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Simon ST, Köskeroglu P, Gaertner J, Voltz R. Fentanyl for the relief of refractory breathlessness: a systematic review. J Pain Symptom Manage 2013; 46:874-86. [PMID: 23742735 DOI: 10.1016/j.jpainsymman.2013.02.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/03/2013] [Accepted: 02/18/2013] [Indexed: 11/30/2022]
Abstract
CONTEXT Fentanyl is a potent opioid that has been proven to provide effective treatment for breakthrough cancer pain. Although opioids are the only drug group with evidence for the symptomatic treatment of breathlessness, evidence about the efficacy of fentanyl for the relief of breathlessness is unknown. OBJECTIVES We performed a systematic review to evaluate the current evidence for the use of fentanyl for the relief of breathlessness. METHODS The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendation for systematic reviews. Four databases (MEDLINE, EMBASE, Cochrane Library, International Pharmaceutical Abstracts) were screened using "fentanyl" and "dyspnoea" (and synonyms) as search terms. Hand search and contact with relevant authors completed the search. RESULTS A total of 622 references were retrieved, 13 of which met the inclusion criteria for this review. Two randomized controlled trials (RCTs) evaluated fentanyl for breathlessness, but one only included two patients. The other studies were before-after (n = 2) and case studies (n = 9). All studies reported successful relief of breathlessness after fentanyl application, but the only (pilot-) RCT failed to demonstrate a statistically significant difference compared with placebo. The nature and incidence of adverse events were comparable with other opioids, and no respiratory depression was observed. CONCLUSION Descriptive studies yielded promising results for the use of fentanyl for the relief of breathlessness; however, efficacy trials are lacking. Fully powered RCTs are warranted to determine the efficacy of fentanyl for breathlessness relief, but these require pilot studies to evaluate effective size, study procedures, and outcome measures.
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Affiliation(s)
- Steffen T Simon
- Center of Palliative Medicine and Clinical Trials Unit (BMBF 01KN1106), University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Cologne-Bonn, University Hospital of Cologne, Cologne, Germany.
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Gaertner J, Drabik A, Marschall U, Schlesiger G, Voltz R, Stock S. Inpatient Palliative Care: A nationwide analysis. Health Policy 2013; 109:311-8. [DOI: 10.1016/j.healthpol.2012.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 06/19/2012] [Accepted: 07/22/2012] [Indexed: 10/28/2022]
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Abstract
OBJECTIVE This study aims to identify the combination of substances with high potential for drug interactions in a palliative care setting and to provide concise recommendations for physicians. METHODS We used a retrospective systematic chart analysis of 200 consecutive inpatients. The recently developed and internationally advocated classification system OpeRational ClAssification of Drug Interactions was applied using the national database of the Federal Union of German Associations of Pharmacists. Charts of patients with potential for severe DDIs were examined manually for clinical relevance. RESULTS In 151 patients (75%) a total of 631 potential drug interactions were identified. Opioids (exception: methadone), non-opioids (exception: non-steroidal anti-inflammatory drugs), benzodiazepines, proton-pump inhibitors, laxatives, co-analgesics (exception: carbamazepine) and butylscopolamine were generally safe. High potential for drug interactions included combinations of scopolamine, neuroleptics, metoclopramide, antihistamines, non-steroidal anti-inflammatory drugs, (levo-) methadone, amitriptyline, carbamazepine and diuretics. The manual analyses of records from eight patients with risk for severe drug interactions provided no indicator for clinical relevance in these specific patients. Drug interactions attributed to the cytochrome pathway played a minor role (exception: carbamazepine). CONCLUSION Most relevant drug interactions can be expected with: (i) drugs (inter-) acting via histamine, acetylcholine or dopamine receptors; and (ii) Non-steroidal anti-inflammatory drugs. Even in last hours of life the combination of substances (e.g. anticholinergics) may produce relevant drug interactions (e.g. delirium). PERSPECTIVE Data on the potential for drug-drug interactions in palliative case is extremely scarce, but drug interactions can be limited if a few facts are considered. A synopsis of the findings of these studies is presented as concise recommendation to minimize drug interactions.
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Affiliation(s)
- Jan Gaertner
- Department of Palliative Medicine, University Hospital Cologne, Germany.
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Abstract
Breast cancer patients with bone metastases often suffer from cancer pain. In general, cancer pain treatment is far from being optimal for many patients. To date, morphine remains the gold standard as first-line therapy, but other pure μ agonists such as hydromorphone, fentanyl, or oxycodone can be considered. Transdermal opioids are an important option if the oral route is impossible. Due to its complex pharmacology, methadone should be restricted to patients with difficult pain syndromes. The availability of a fixed combination of oxycodone and naloxone is a promising development for the reduction of opioid induced constipation. Especially bone metastases often result in breakthrough pain episodes. Thus, the provision of an on-demand opioid (e.g., immediate-release morphine or rapid-onset fentanyl) in addition to the baseline (regular) opioid therapy (e.g., sustained-release morphine tablets) is mandatory. Recently, rapid onset fentanyls (buccal or nasal) have been strongly recommended for breakthrough cancer pain due to their fast onset and their shorter duration of action. If available, metamizole is an alternative non-steroid-anti-inflammatory-drug. The indication for bisphosphonates should always be checked early in the disease. In advanced cancer stages, glucocorticoids are an important treatment option. If bone metastases lead to neuropathic pain, coanalgetics (e.g., pregabalin) should be initiated. In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management. In diffuse bone pain radionuclids (such as samarium) can be beneficial. Invasive measures (e.g., neuroaxial blockage) are rarely necessary but are an important option if patients with cancer pain syndromes are refractory to pharmacologic management and radiotherapy as described above. Clinical guidelines agree that cancer pain management in incurable cancer is best provided as part of a multiprofessional palliative care approach and all other domains of suffering (psychosocial, spiritual, and existential) need to be carefully addressed («total pain»).
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Affiliation(s)
- Guido Schneider
- Department of Palliative Care, University Hospital Cologne, BMBF 01KN1106, Germany
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Balint B, Haas J, Schwarz A, Fuerwentsches A, Ebinger F, Fritzsching B, Seidel U, Paul F, Huppke P, Gaertner J, Wildemann B. B Cells and Subsets in Pediatric-Onset Relapsing-Remitting Multiple Sclerosis: Similarities and Differences to Adult-Onset Disease (P02.126). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p02.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Simon ST, Altfelder N, Voltz R, Gaertner J. [Management of refractory dyspnoea in patients with advanced diseases - evidence-based update for clinical practice]. Ther Umsch 2012; 69:93-7. [PMID: 22334199 DOI: 10.1024/0040-5930/a000258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Many patients with advanced diseases complain about refractory breathlessness when breathlessness is present although the underlying disease is optimal treated. After exclusion of potential curable causes of breathlessness, management of refractory breathlessness includes general approaches, pharmacological (opioids) and non-pharmacological (e.g. handheld fan, rollator) interventions. Oxygen should be used far less than used in clinical practice at the moment and needs critical appraisal of effectiveness.
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Affiliation(s)
- Steffen T Simon
- Universitätsklinik Köln und Institut für Palliative Care, Oldenburg.
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Wuerstlein R, Uellenberg J, Gaertner J, Mallmann P, Voltz R, Harbeck N. 259 Implementation of Palliative Care in German Breast Centers ñ First Results of a National Questionnaire. Eur J Cancer 2012. [DOI: 10.1016/s0959-8049(12)70326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
BACKGROUND Palliative care (PC) infrastructure has developed differently around the globe. Whereas some institutions consider the palliative care unit (PCU) a valuable component, others report that the sole provision of a state-of-the art palliative care consultation service (PCCS) suffices to adequately care for the severely ill and dying. OBJECTIVE To aid institutional planning, this study aimed at gathering patient data to distinguish assignments of a concomitantly run PCU and PCCS at a large hospital and academic medical center. METHODS Demographics, Eastern Cooperative Oncology Group performance status, symptom/problem burden, discharge modality, and team satisfaction with care for all 601 PCU and 851 PCCS patients treated in 2009 and 2010 were retrospectively analyzed. RESULTS Patients admitted to the PCU versus those consulted by the PCCS: (a) had a significantly worse performance status (odds ratio [OR], 1.48); (b) were significantly more likely to suffer from severe symptoms and psychosocial problems (OR, 2.05), in particular concerning physical suffering and complexity of care; and (c) were significantly much more likely to die during hospital stay (OR, 11.03). For patients who were dying or in other challenging clinical situations (suffering from various severe symptoms), self-rated team satisfaction was significantly higher for the PCU than the PCCS. CONCLUSION This study presents a direct comparison between patients in a PCU and a PCCS. Results strongly support the hypothesis that the coexistence of both institutions in one hospital contributes to the goal of ensuring optimal high-quality PC for patients in complex and challenging clinical situations.
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Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, University Hospital Cologne, 50924 Cologne, Germany.
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Pohl G, Marosi C, Dieckmann K, Goldner G, Elandt K, Hassler M, Schemper M, Strasser-Weippl K, Nauck F, Gaertner J, Watzke H. Evaluation of diagnostic and treatment approaches towards acute dyspnea in a palliative care setting among medical students at the University of Vienna. Wien Med Wochenschr 2012; 162:18-28. [DOI: 10.1007/s10354-011-0046-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/16/2011] [Indexed: 12/01/2022]
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Ostgathe C, Voltz R, Van Aaaken A, Klein C, Sabatowski R, Nauck F, Gaertner J. Practicability, safety, and efficacy of a "German model" for opioid conversion to oral levo-methadone. Support Care Cancer 2011; 20:2105-10. [PMID: 22130587 DOI: 10.1007/s00520-011-1320-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 11/01/2011] [Indexed: 10/15/2022]
Abstract
INTRODUCTION An algorithm to convert from any other opioid to oral levo-methadone was developed in Germany, the German model of levo-methadone conversion (GMLC). According to this GMLC, the pre-existing opioid is stopped, then titration of oral levo-methadone is initiated with a starting dose of 5 mg orally q 4 h (plus prn q 1 h). If necessary, levo-methadone dose is increased (pain) or decreased (side effects) by 30% q 4 h (plus prn q 1 h). After 72 h, the achieved single dose is maintained, but the dosing interval increases twofold to q 8 h (plus prn q 3 h). The aim of this study was to obtain information about the practicability, safety, and efficacy of the GMLC in clinical routine. METHODS A retrospective, systematic chart review of levo-methadone conversions for the treatment of pain in inpatient palliative care was performed. RESULTS Fifty-two patients were analyzed. The dosing interval was increased correctly after 72 h as demanded by the GMLC in 60% of patients. In 85% of the patients, opioid medication with levo-methadone could be maintained until the end of the inpatient stay. In three patients (6%), levo-methadone administration had to be stopped due to side effects. No serious adverse events could be detected during opioid rotation. Pain intensity was reduced significantly (p < 0.001) after conversion concerning mean (NRS 0.9; range 0-4) and maximum pain over the day (NRS 3.9; range 0-10). CONCLUSION The presented study indicates that the GMLC provides a practical and reasonably safe approach to perform opioid rotation to levo-methadone in a palliative care setting.
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Affiliation(s)
- Christoph Ostgathe
- Division of Palliative Medicine, University of Erlangen, Erlangen, Germany.
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