Delirium in advanced cancer patients: prospective, observational study in two different palliative care settings

Introduzione. Il Delirium è una sindrome neuropsichiatrica frequente nei pazienti oncologici. La Memorial Delirium Assessment Scale (MDAS) è uno strumento validato per diagnosi, severità e fenomenologia del delirium. Scopo dello studio: confrontar prevalenza all’ingresso, incidenza durante il ricovero e fenomenologia del delirium, in pazienti affetti da malattia oncologica avanzata in due diversi setting: Hospice e reparto di Oncologia. Metodi. Abbiamo condotto uno studio osservazionale prospettico in pazienti ricoverati nell’Hospice Bentivoglio della Fondazione Hospice MT Chiantore Seràgnoli Onlus (Bentivoglio, Bologna, Italy) (FHS) e presi in carico dalla Equipe di Cure Palliative del reparto di Oncologia della Clinica Università di Navarra (Pamplona, Spain) (CUN). L’MDAS è stato somministrato all’ingresso e una volta alla settimana. Sono state eseguite analisi di frequenza, Test Chi-quadrato Pearson, Test esatto di Fisher, Test Anova e Test Wilcoxon. Resultati. Sono stati arruolati 227 pazienti (176 in FSH, 51 in CUN). La prevalenza di delirium all’ingresso è stata di 46/176 (26%) pazienti in FHS e 11/51 (22%) in CUN (p<0.585). L’incidenza durante il ricovero è stata di 31/176 (18%) pazienti in FHS e di 4/51 (8%) in CUN (p<0.208). Alla dimissione/decesso, il delirium è stato irreversibile in 65/176 (37%) pazienti in FHS e in 3/51 (6%) in CUN (p<0.001). In 32 pazienti è stato possibile confrontare l’MDAS all’episodio di delirium con il successivo. Nei 22 pazienti con delirium reversibile tutti gli item dell’MDAS sono migliorati (riduzione del livello di intensità); nei 10 pazienti con delirium irreversibile, il livello di intensità è rimasto lo stesso in tutti gli item. Conclusione. La prevalenza del delirium all’ingresso e l’incidenza durante il ricovero sono stati simili nei due setting, l’evoluzione diversa: in FSH alla dimissione/decesso ci sono stati un numero maggiore di delirium irreversibili. Con precoce diagnosi e trattamento il delirium può migliorare quando reversibile, può non peggiorare quando irreversibile.Background. Delirium is a neuropsychiatric syndrome more frequent in advanced cancer patients. The Memorial Delirium Assessment Scale (MDAS) is a validated tool used for diagnosis, severity and measuring phenomenology of delirium. The aim of this study is to compare the prevalence at admission, incidence during hospitalization and phenomenology of delirium in advanced cancer patients in two different settings: a hospice and an oncology ward. Methods. We conducted a prospective observational study of patients admitted at Hospice Bentivoglio of the Hospice MT Chiantore Seràgnoli Onlus Foundation (Bentivoglio, Bologna, Italy) (FHS) and attended by the Palliative Care Supportive Team at the Oncology Ward of the University Clinic of Navarra (Pamplona, Spain) (CUN). MDAS was administered at initial hospitalization and repeated every week. Frequency analysis, Chi-squared Pearson Test, Fisher test, Anova Test and Wilcoxon test were analyzed. Results. 227 were enrolled (176 in FHS, 51 in CUN). Delirium prevalence was 26% (46/176) FHS, 22% (11/51) CUN (p<0.585). Delirium incidence was diagnosed in 18% (31/176) of patients in FHS, in 8% (4/51) at CUN (p<0.208). At the time of discharge/death, irreversible delirium was present in 37% (65/176) of patients at FHS, in 6% (3/51) at CUN (p<0.001). In a subset of 32 patients, MDAS was compared at the time of diagnosis of delirium and one week later. In 22 patients with reversible delirium, all MDAS items showed a reduction in the level of intensity of delirium, but in 10 patients with irreversible delirium, the level of all items reminded at the same intensity. Conclusion. Delirium prevalence at admission and incidence during hospitalization was similar in both settings, but the evolution was different: in FSH at discharge/death, there was a higher prevalence of irreversible delirium. Signs of delirium can improve in reversible delirium and not worsen in irreversible delirium by early diagnosis and proper treatment

Androgenetic alopecia: a review

Purpose Androgenetic alopecia, commonly known as male pattern baldness, is the most common type of progressive hair loss disorder in men. The aim of this paper is to review recent advances in understanding the pathophysiology and molecular mechanism of androgenetic alopecia. Methods Using the PubMed database, we conducted a systematic review of the literature, selecting studies pub- lished from 1916 to 2016. Results The occurrence and development of androgenetic alopecia depends on the interaction of endocrine factors and genetic predisposition. Androgenetic alopecia is character- ized by progressive hair follicular miniaturization, caused by the actions of androgens on the epithelial cells of genetically susceptible hair follicles in androgen-dependent areas. Although the exact pathogenesis of androgenetic alopecia remains to be clari fi ed, research has shown that it is a polygenetic condition. Numerous studies have unequi- vocally identi fi ed two major genetic risk loci for androge- netic alopecia, on the X-chromosome AR ⁄ EDA2R locus and the chromosome 20p11 locus. Conclusions Candidate gene and genome-wide association studies have reported that single-nucleotide polymorphisms at different genomic loci are associated with androgenetic alopecia development. A number of genes determine the predisposition for androgenetic alopecia in a polygenic fashion. However, further studies are needed before the specific genetic factors of this polygenic condition can be fully explaine

Methadone as First-line Opioid for the Management of Cancer Pain

Aim The aim of this study was to assess the efficacy and adverse effects of methadone when used as first-line therapy in patients that are either receiving low doses of opioids or none. Methods Patients with advanced cancer were prospectively assessed. Opioid-naive patients (L-group) were started with methadone at 6 mg/day. Patients receiving weak or other opioids in doses of &lt;60 mg/day of OME (H-group) were started with methadone at 9 mg/day. Methadone doses were changed according to the clinical needs to obtain the most favorable balance between analgesia and adverse effects. Edmonton Symptom Asssement Score (ESAS), Memorial Delirium Assessment Score (MDAS), doses of methadone, and the use of adjuvant drugs were recorded before starting the study treatment (T0), 1 week after (T7), 2 weeks after (T14), 1 month after (T30), and 2 months after (T60). Methadone escalation index percent (MEI%) and in mg (MEImg) were calculated at T30 and T60. Results Eighty-two patients were assessed. In both groups H and L, there were significant changes in pain and symptom intensity at the different times during the study. Adverse effects as causes of drop-out were minimal. Mean MEImg was 0.09 (SD 0.28) and 0.02 (SD 0.07) at T30 and T60, respectively. MEI% was 1.01 (SD 3.08) and 0.27 (SD 0.86) at T30 and T60, respectively. Conclusion Methadone used as a first-line opioid therapy provided good analgesia with limited adverse effects and a minimal opioid-induced tolerance

Nurse-led telephone follow-up for early palliative care patients with advanced cancer

Aim and objectives To present our experience of a nursing telephone consultation service, describing patient and caregiver requests, and outlining ensuing nursing or medical interventions. Background Recently, there has been an increase in the use of telephone consultation for cancer patients. However, there is still limited data on the characteristics of this type of service and on the nature of the interventions carried out. Design and methods In this observational retrospective study, we evaluated the phone calls made over a 6-month period by patients or caregivers to the early palliative care team of a cancer institute. Information regarding telephone calls (frequency, reason and management) was systematically collected by a nursing case manager. The study complies with the STROBE checklist File S1. Results 171 patients used the service, for a total of 323 phone calls. The majority (80.8%) were from patients followed at the outpatient clinic and the most common requests were for pain management (38.4%) and for updates on the clinical situation (23.8%). Other frequent requests were for medication management (18.9%) and scheduling (18.3%). 210 of the 323 phone calls were handled by the nurse, while 22 were managed in collaboration with a physician. An 87.6% effectiveness in telephone management was observed. Conclusion The overall use of the phone service was higher for early palliative care patients. The majority of phone calls were effectively handled by the nursing case manager. Relevance to clinical practice An effective and feasible nurse-led telephone follow-up of early palliative care patients with advanced cancer could improve their care experience. Specifically, it could impact on patients and families improving quality of life and symptom control securing access to timely care without travel or additional cost.It can also improve continuity of care, adherence to oncological treatments and minimise acute care visits

Successful radiotherapy for local control of progressively increasing metastasis of gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) are known to be poorly responsive to conventional chemotherapy and historically considered resistant to radiotherapy. In the past the mainstay of GIST treatment was surgery, but the introduction of tyrosine kinase inhibitors (TKIs) imatinib and sunitinib marked the beginning of a new era in the treatment of GIST patients. To date, radiotherapy for GIST has not been administered in clinical practice except for limited palliative settings and there are no clear data on the administration of radiotherapy, alone or in combination with TKIs, with a purely cytoreductive intent. We describe the clinical case of a 48-year-old woman with metastatic GIST treated with external radiotherapy in a critical supraclavicular tumor localization progressively increasing in size with several symptoms and not responsive to systemic TKI therapies. We obtained an initial shrinkage of the mass and subsequent stabilization with an immediate and clear clinical benefit. Although the historical medical literature considered GISTs resistant to radiation therapy, our clinical case suggests this treatment may be appropriate in selected patients

Thalidomide-dexamethasone as induction therapy before autologous stem cell transplantation in patients with newly diagnosed multiple myeloma and renal insufficiency.

The aim of this study was to evaluate the efficacy and the toxicity of thalidomide-dexamethasone (Thal-Dex) as induction therapy before autologous peripheral blood stem cell (PBSC) transplantation in patients with newly diagnosed multiple myeloma (MM) with renal insufficiency. The study included 31 patients with a baseline creatinine clearance value ≤50 mL/min, 7 of whom required chronic hemodialysis. Patients received 4 months of Thal-Dex, followed by PBSC collection and subsequent transplantation. After induction, a partial response (PR) or greater was obtained in 23 patients (74%), including 8 (26%) who achieved a very good PR. Renal function improved more frequently in patients achieving a PR or greater (82%, vs 37% in patients achieving less than a PR; P = .04). Twenty-six patients underwent PBSC mobilization; in 17 of these patients (65%), >4 × 10 6 CD34 + cells/kg were collected. Double autologous transplantation was performed in 15 patients, and a single autologous transplantation was performed in 7 patients. After a median of 32 months of follow-up, median event-free survival was 30 months, and median survival was not determined. According to our data, Thal-Dex is effective and safe in patients with newly diagnosed MM and renal insufficiency. Given the relationship between recovery of renal function and response to induction treatment, more intensive Thal + bortezomib regimens could be explored to rescue higher numbers of patients

Prognostication in palliative radiotherapy-ProPaRT: Accuracy of prognostic scores

BackgroundPrognostication can be used within a tailored decision-making process to achieve a more personalized approach to the care of patients with cancer. This prospective observational study evaluated the accuracy of the Palliative Prognostic score (PaP score) to predict survival in patients identified by oncologists as candidates for palliative radiotherapy (PRT). We also studied interrater variability for the clinical prediction of survival and PaP scores and assessed the accuracy of the Survival Prediction Score (SPS) and TEACHH score. Materials and methodsConsecutive patients were enrolled at first access to our Radiotherapy and Palliative Care Outpatient Clinic. The discriminating ability of the prognostic models was assessed using Harrell's C index, and the corresponding 95% confidence intervals (95% CI) were obtained by bootstrapping. ResultsIn total, 255 patients with metastatic cancer were evaluated, and 123 (48.2%) were selected for PRT, all of whom completed treatment without interruption. Then, 10.6% of the irradiated patients who died underwent treatment within the last 30 days of life. The PaP score showed an accuracy of 74.8 (95% CI, 69.5-80.1) for radiation oncologist (RO) and 80.7 (95% CI, 75.9-85.5) for palliative care physician (PCP) in predicting 30-day survival. The accuracy of TEACHH was 76.1 (95% CI, 70.9-81.3) and 64.7 (95% CI, 58.8-70.6) for RO and PCP, respectively, and the accuracy of SPS was 70 (95% CI, 64.4-75.6) and 72.8 (95% CI, 67.3-78.3). ConclusionAccurate prognostication can identify candidates for low-fraction PRT during the last days of life who are more likely to complete the planned treatment without interruption.All the scores showed good discriminating capacity; the PaP had the higher accuracy, especially when used in a multidisciplinary way

Three cases of bone metastases in patients with gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are rare, but represent the most common mesenchymal neoplasms of the gastrointestinal tract. Tumor resection is the treatment of choice for localized disease. Tyrosine kinase inhibitors (imatinib, sunitinib) are the standard therapy for metastatic or unresectable GISTs. GISTs usually metastasize to the liver and peritoneum. Bone metastases are uncommon. We describe three cases of bone metastases in patients with advanced GISTs: two women (82 and 54 years of age), and one man (62 years of age). Bones metastases involved the spine, pelvis and ribs in one patient, multiple vertebral bodies and pelvis in one, and the spine and iliac wings in the third case. The lesions presented a lytic pattern in all cases. Two patients presented with multiple bone metastases at the time of initial diagnosis and one patient after seven years during the follow-up period. This report describes the diagnosis and treatment of the lesions and may help clinicians to manage bones metastases in GIST patients