Systematic versus on-demand early palliative care: results from a multicentre, randomised clinical trial

Background Early palliative care (EPC) in oncology has been shown to have a positive impact on clinical outcome, quality-of-care outcomes, and costs. However, the optimal way for activating EPC has yet to be defined. Methods This prospective, multicentre, randomised study was conducted on 207 outpatients with metastatic or locally advanced inoperable pancreatic cancer. Patients were randomised to receive ‘standard cancer care plus on-demand EPC’ (n = 100) or ‘standard cancer care plus systematic EPC’ (n = 107). Primary outcome was change in quality of life (QoL) evaluated through the Functional Assessment of Cancer Therapy – Hepatobiliary questionnaire between baseline (T0) and after 12 weeks (T1), in particular the integration of physical, functional, and Hepatic Cancer Subscale (HCS) combined in the Trial Outcome Index (TOI). Patient mood, survival, relatives' satisfaction with care, and indicators of aggressiveness of care were also evaluated. Findings The mean changes in TOI score and HCS score between T0 and T1 were −4.47 and −0.63, with a difference between groups of 3.83 (95% confidence interval [CI] 0.10–7.57) (p = 0.041), and −2.23 and 0.28 (difference between groups of 2.51, 95% CI 0.40–4.61, p = 0.013), in favour of interventional group. QoL scores at T1 of TOI scale and HCS were 84.4 versus 78.1 (p = 0.022) and 52.0 versus 48.2 (p = 0.008), respectively, for interventional and standard arm. Until February 2016, 143 (76.9%) of the 186 evaluable patients had died. There was no difference in overall survival between treatment arms. Interpretations Systematic EPC in advanced pancreatic cancer patients significantly improved QoL with respect to on-demand EPC

Overview of the FTU results

Since the 2018 IAEA FEC Conference, FTU operations have been devoted to several experiments covering a large range of topics, from the investigation of the behaviour of a liquid tin limiter to the runaway electrons mitigation and control and to the stabilization of tearing modes by electron cyclotron heating and by pellet injection. Other experiments have involved the spectroscopy of heavy metal ions, the electron density peaking in helium doped plasmas, the electron cyclotron assisted start-up and the electron temperature measurements in high temperature plasmas. The effectiveness of the laser induced breakdown spectroscopy system has been demonstrated and the new capabilities of the runaway electron imaging spectrometry system for in-flight runaways studies have been explored. Finally, a high resolution saddle coil array for MHD analysis and UV and SXR diamond detectors have been successfully tested on different plasma scenarios

Overview of the FTU results

Since the 2016 IAEA Fusion Energy Conference, FTU operations have been mainly devoted to experiments on runaway electrons and investigations into a tin liquid limiter; other experiments have involved studies of elongated plasmas and dust. The tearing mode onset in the high density regime has been studied by means of the linear resistive code MARS, and the highly collisional regimes have been investigated. New diagnostics, such as a runaway electron imaging spectroscopy system for in-flight runaway studies and a triple Cherenkov probe for the measurement of escaping electrons, have been successfully installed and tested, and new capabilities of the collective Thomson scattering and the laser induced breakdown spectroscopy diagnostics have been explored

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Erratum to \u201cSystematic versus on-demand early palliative care: A randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life\u201d [Eur J Cancer (2016) 69 (110\u2013118)] (S095980491632487X)(10.1016/j.ejca.2016.10.004)

The publisher regrets that the collaborators for this paper were not listed as such within the author details of the published paper. The collaborators were published in the Acknowledgements and are as follows: Alberto Farolfi, Silvia Ruscelli, Martina Valgiusti, Sara Pini, Marina Faedi, Department of Medical Oncology, IRST IRCCS, Meldola; Angela Ragazzini, Unit of Biostatistics and Clinical Trials, IRST IRCCS, Meldola; Cristina Pittureri and Elena Amaducci, Palliative Care and Hospice Unit, AUSL Romagna, Cesena; Irene Guglieri, Psychooncology Service, Veneto Institute of Oncology IOV \u2013 IRCCS, Padua; Francesca Bergamo, Sara Lonardi, Department of Clinical and Experimental Oncology, Medical Oncology 1, Veneto Institute of Oncology IOV \u2013 IRCCS, Padua; Camilla Di Nunzio, Medical Oncology Unit, Oncology\u2013Hematology Department, Guglielmo da Saliceto Hospital, Piacenza; Monica Bosco, Palliative Care Unit, Oncology\u2013Hematology Department, Guglielmo da Saliceto Hospital, Piacenza; Barbara Bocci, Medical Oncology Unit, San Paolo Hospital, Milan; Alfina Bramanti and Chiara Gandini, Oncology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia; Angela Buonadonna, Medical Oncology Unit, Aviano National Cancer Institute, Aviano; Alessandro Comandone, Medical Oncology Unit, Presidio Humanitas Gradenigo, Turin; Sonia Zoccali, Coordinamento Cure Palliative (supported by F.I.L.E., Leniterapia Italian Foundatio), Florence; Maria Simona Pino, Medical Oncology Unit, Oncology Department, S. Maria Annunziata Hospital, Florence; Davide Dalu, Palliative Care Unit, Oncology Department, L. Sacco Hospital, Milan; Pietro Sozzi, Oncology Unit, Ospedale degli Infermi, Ponderano; Alberto Gozza, Medical Oncology, Department of Medicine, E.O. Galliera Hospitals, Genoa; Monica Giordano and Carla Longhi, Oncology Unit, Sant'Anna Hospital, Como; Cristina Autelitano, Palliative Care Unit, Arcispedale S. Maria Nuova \u2013 IRCCS, Reggio Emilia; Teresa Gamucci, Oncology Unit, SS Trinit\ue0 Hospital Sora, ASL Frosinone, Frosinone; Cataldo Mastromauro, Oncology Unit, ULSS 12 Veneziana, Venice; Rodolfo Scognamiglio, Hospice Nazareth, Mestre; Daniela Degiovanni, Palliative Care Unit, Casale Monferrato, ASL Alessandria; Federica Negri, Medical Oncology Unit, Istituti Ospitalieri, Cremona; Augusto Caraceni, Palliative Care, Pain Therapy and Rehabilitation Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan; and Luigi Montanari, Palliative Care Unit Ravenna, AUSL Romagna, Italy. The publisher would like to apologise for any inconvenience caused

Overview of FTU results

New FTU ohmic discharges with a liquid lithium limiter at I(P) = 0.7-0.75 MA, B(T) = 7 T and n(e0) >= 5 x 10(20) m(-3) confirm the spontaneous transition to an enhanced confinement regime, 1.3-1.4 times ITER-97-L, when the density peaking factor is above a threshold value of 1.7-1.8. The improved confinement derives from a reduction of electron thermal conductivity (chi(e)) as density increases, while ion thermal conductivity (chi(i)) remains close to neoclassical values. Linear microstability reveals the importance of lithium in triggering a turbulent inward flux for electrons and deuterium by changing the growth rates and phase of the ion-driven turbulence, while lithium flux is always directed outwards. A particle diffusion coefficient, D similar to 0.07 m(2) s(-1), and an inward pinch velocity, V similar to 0.27 ms(-1), in qualitative agreement with Bohm-gyro-Bohm predictions are inferred in pellet fuelled lithized discharges. Radio frequency heated plasmas benefit from cleaner plasmas with edge optimized conditions. Lower hybrid waves penetration and current drive effects are clearly demonstrated at and above ITER densities thanks to a good control of edge parameters obtained by plasma operations with the external poloidal limiter, lithized walls and pellet fuelling. The electron cyclotron (EC) heating system is extensively exploited in FTU for contributing to ITER-relevant issues such as MHD control: sawtooth crash is actively controlled and density limit disruptions are avoided by central and off-axis deposition of 0.3 MW of EC power at 140 GHz. Fourier analysis shows that the density drop and the temperature rise, stimulated by modulated EC power in low collisionality plasmas are synchronous, implying that the heating method is the common cause of both the electron heating and the density drop. Perpendicularly injected electron cyclotron resonance heating is demonstrated to be more efficient than the obliquely injected one, reducing the minimum electric field required at breakdown by a factor of 3. Theoretical activity further develops the model to interpret high-frequency fishbones on FTU and other experiments as well as to characterize beta-induced Alfven eigenmodes induced by magnetic islands in ohmic discharges. The theoretical framework of the general fishbone-like dispersion relation is used for implementing an extended version of the HMGC hybrid MHD gyrokinetic code. The upgraded version of HMGC will be able to handle fully compressible non-linear gyrokinetic equations and 3D MHD

Overview of FTU results

New FTU ohmic discharges with a liquid lithium limiter at IP = 0.7–0.75 MA, BT = 7 T and ne0 ≥ 5 × 1020 m−3 confirm the spontaneous transition to an enhanced confinement regime, 1.3–1.4 times ITER-97-L, when the density peaking factor is above a threshold value of 1.7–1.8. The improved confinement derives from a reduction of electron thermal conductivity (χe) as density increases, while ion thermal conductivity (χi) remains close to neoclassical values. Linear microstability reveals the importance of lithium in triggering a turbulent inward flux for electrons and deuterium by changing the growth rates and phase of the ion-driven turbulence, while lithium flux is always directed outwards. A particle diffusion coefficient, D ~ 0.07 m2 s−1, and an inward pinch velocity, V ~ 0.27 m s−1, in qualitative agreement with Bohm–gyro-Bohm predictions are inferred in pellet fuelled lithized discharges. Radio frequency heated plasmas benefit from cleaner plasmas with edge optimized conditions. Lower hybrid waves penetration and current drive effects are clearly demonstrated at and above ITER densities thanks to a good control of edge parameters obtained by plasma operations with the external poloidal limiter, lithized walls and pellet fuelling. The electron cyclotron (EC) heating system is extensively exploited in FTU for contributing to ITER-relevant issues such as MHD control: sawtooth crash is actively controlled and density limit disruptions are avoided by central and off-axis deposition of 0.3 MW of EC power at 140 GHz. Fourier analysis shows that the density drop and the temperature rise, stimulated by modulated EC power in low collisionality plasmas are synchronous, implying that the heating method is the common cause of both the electron heating and the density drop. Perpendicularly injected electron cyclotron resonance heating is demonstrated to be more efficient than the obliquely injected one, reducing the minimum electric field required at breakdown by a factor of 3. Theoretical activity further develops the model to interpret high-frequency fishbones on FTU and other experiments as well as to characterize beta-induced Alfvén eigenmodes induced by magnetic islands in ohmic discharges. The theoretical framework of the general fishbone-like dispersion relation is used for implementing an extended version of the HMGC hybrid MHD gyrokinetic code. The upgraded version of HMGC will be able to handle fully compressible non-linear gyrokinetic equations and 3D MHD