PC-FACS
2018; Elsevier BV; Volume: 55; Issue: 3 Linguagem: Inglês
10.1016/j.jpainsymman.2018.01.001
ISSN1873-6513
Autores Tópico(s)Neonatal Respiratory Health Research
ResumoPC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at . PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at . Grenald SA, Doyle TM, Zhang H, et al. Targeting the S1P/S1PR1 axis mitigates cancer-induced bone pain and neuroinflammation. Pain. 2017;158(9):1733-1742. Lindquist LA, Ramirez-Zohfeld V, Sunkara PD, et al. Helping seniors plan for posthospital discharge needs before a hospitalization occurs: results from the randomized control trial of PlanYourLifespan.org. J Hosp Med. 2017;12(11):911-917. Liberman T, Kozikowski A, Kwon N, Emmert B, Akerman M, Pekmezaris R. Identifying advanced illness patients in the emergency department and having goals-of-care discussions to assist with early hospice referral [published online ahead of print on October 5, 2017]. J Emerg Med. pii: S0736-4679(17)30714-X. https://doi.org/10.1016/j.jemermed.2017.08.009. Lazzarin P, Schiavon B, Brugnaro L, Benini F. Parents spend an average of nine hours a day providing palliative care for children at home and need to maintain an average of five life-saving devices [published online ahead of print on September 25, 2017]. Acta Paediatr. https://doi.org/10.1111/apa.14098. El-Jawahri A, Traeger L, Greer JA, et al. Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: results of a randomized clinical trial. J Clin Oncol. 2017;35(32):3714-3721. Yennurajalingam S, Tannir NM, Williams JL, et al. A double-blind, randomized, placebo-controlled trial of Panax ginseng for cancer-related fatigue in patients with advanced cancer. J Natl Compr Canc Netw. 2017;15(9):1111-1120. Cancer-induced bone pain (CIBP) is reported by 30% to 50% of all cancer patients and by 75% to 90% of late-stage patients.1 Is the FDA-approved drug FTY720 (a functional sphingosine 1-phosphate receptor subtype (S1PR1) antagonist) an effective inhibitor of CIBP? This study used a murine breast cancer metastasis model to test whether an alteration in spinal sphingolipid content (sphingolipid metabolism alterations in the spinal cord [SC]) may underlie the maintenance of CIBP. Femoral arthrotomy, with injection of murine 66.1 mammary adenocarcinoma cells, was performed. On postsurgery day 7, test compounds were administered intrathecally or subcutaneously. Pain behaviors (flinching and guarding) were measured presurgery and on postsurgery day 10 for acute treatment studies or on days 7, 10, and 14 for continuous treatment studies. Mass spectrometry sphingolipid analysis of lumbar SCs (ipsilateral to the 66.1-cell injection site), lumbar SC cytokine-level assessments, radiographic bone loss scoring, and a serum biochemical assay were used to assess FTY720 for treating CIBP. Two-way ANOVA with Bonferroni correction, t-tests, and the Benjamini-Hochberg procedure were used. Following arthrotomy and tumor implantation, ceramides decreased, S1P increased, and sphingolipid biosynthesis increased (as shown by elevations of dihydro-ceramides and dihydro-S1P; all P<0.03). Intrathecal or systemic administration of competitive and functional S1PR1 antagonists, TASP0277308 and FTY720/Fingolimod, respectively, attenuated cancer-induced flinching and guarding (P<0.05). Inhibiting CIBP via systemic FTY720 did not produce antinociceptive tolerance or alter bone metabolism over 7 days. FTY720 enhanced IL-10 in the lumbar ipsilateral SC and an IL-10 neutralizing antibody (intrathecal) reduced FTY720 reversal of CIBP (P<0.05). FTY720 is an S1PR1 receptor antagonist FDA-approved as Fingolimod (Gilenya®), a clinically immunomodulating therapy for relapsing forms of multiple sclerosis. It acts to decrease ceramide, a proinflammatory, proapoptic sphingolipid recently associated with neuropathic pain. The concept that painful peripheral bone tumor burden elicits alteration in spinal cord sphingolipid metabolism has been demonstrated and suggests a central neuropathic characteristic of CIBP. Studies of FTY720 clinical application to patients with CIBP are likely to follow. If successful, we may see a significant turning point in CIBP management. This laboratory model of CIBP in mice has identified the sphingosine 1-phosphate receptor subtype as a novel target for therapeutic intervention. Rosene D. Pirrello, BPharm RPh, University of California-Irvine, Orange, CA. Grenald SA, Doyle TM, Zhang H, et al. Targeting the S1P/S1PR1 axis mitigates cancer-induced bone pain and neuroinflammation. Pain. 2017;158(9):1733-1742. 1.Sabino MA, Mantyh PW. Pathophysiology of bone cancer pain. J Support Oncol. 2005;3(1):15–24. Hospitalized seniors frequently are too sick to make informed decisions about their postdischarge care.1 Can PlanYourLifespan.org (PYL) fill the knowledge gap in understanding postdischarge options? This multisite, randomized control trial (October 2014 to September 2015) investigated the effect of PYL (a national, publicly-available tool providing education on posthospital therapy choices and local home-based resources) on knowledge of posthospital discharge options. Nonhospitalized adults living in urban, suburban, and rural areas of Texas, Illinois, and Indiana were recruited by community-based patient partners/stakeholders through word of mouth, e-mail blasts, newsletters, and flyers. Interested, eligible subjects completed an in-person baseline survey, followed by exposure to intervention or control websites; a post-test survey; and 1-month and 3-month telephone surveys. The primary knowledge outcome was measured with 6 items (possible 0-6 points) pertaining to hospital discharge needs (understanding home services [UHS]). Analysis (intention-to-treat) included linear-mixed modeling. Participants (n=191 control, n=194 intervention) were mean (SD) age 72 (5.6) years, 80% female, 63% white, and 42% married. Fifty percent had income <$40,000 and 51% graduated college. Between-group baseline characteristics were similar. At 1 and 3 months, the intervention group mean UHS score increased (0.56±1.55 and 0.60±1.63, respectively), while the control group score decreased (−0.09±1.43 and −0.07±1.37, respectively). Higher levels of income (P=0.0191), health literacy (P=0.0036), and education (P=0.0042) were associated with increased UHS scores, while male sex (P=0.0023) and history of high blood pressure (P=0.0409) or kidney disease (P=0.0278) were negatively associated with UHS scores. Controlling for these variables, treatment effect remained significant (P<0.0001). “Doc, when do I go home?” is a common question heard by physicians. Hospital discharge planning, especially for the elderly and their families, often is complex because of medical concerns, insurance limitations, and a general lack of understanding of available community resources. Use of PlanYourLifespan.org focuses on alleviating common concerns facing this vulnerable group, including issues of dementia and falls. The importance of this study is magnified as approximately one third of US hospitalizations come from this geriatric population. By employing user friendly and age appropriate health literacy learning modalities, including videos, patients were helped to mitigate posthospital concerns. Importantly, this intervention provided patients resources on a key goal of maintaining their independence. The program also decreased angst of families by aiding in advance care planning. Providing elderly patients and their loved ones with prehospital admission resources regarding discharge options appears to have physical, psychosocial, and financial advantages. David B. Brecher, MD FAAFP FAAHPM, BayCare Health System, North Bay Hospital, New Port Richey, FL. Lindquist LA, Ramirez-Zohfeld V, Sunkara PD, et al. Helping seniors plan for posthospital discharge needs before a hospitalization occurs: results from the randomized control trial of PlanYourLifespan.org. J Hosp Med. 2017;12(11):911-917. 1.Kane RL. Finding the right level of posthospital care: “We didn’t realize there was any other option for him.” JAMA. 2011;305(3):284–293. The emergency department (ED) is a suboptimal setting for relieving end-of-life pain and suffering, yet it is the place where many patients with advanced illness (AI) die.1 Can an AI management program in the ED improve quality of life for patients and decrease their risk of receiving burdensome treatments? This study used a pre-post design with a retrospective chart review to investigate the impact of an AI management program in the ED at an academic tertiary care metropolitan hospital. The baseline and intervention periods were November 2013-December 2014 and January 2015-February 2016. Program goals: screen ED patients for AI, train ED healthcare providers in goals-of-care (GOC) discussions, conduct ED-led GOC promptly, and develop a safe discharge to hospice for appropriate patients. Changes in percent of ED patients identified with AI, percent who received an ED-led GOC discussion, and percent referred to hospice from the ED were assessed. The Mann-Whitney and Fisher’s exact tests were used. Baseline (n=21; median age 75 years) and intervention (n=61; 83) participants were 66% female, and 72% of participants were brought to the ED from home; between-group characteristics did not differ. Intervention patients were likelier to be identified as having AI (90% vs. 0%), to receive a GOC conversation (84% vs. 0%), to be discharged to home hospice (39% vs. 0%; all P 5 required significantly more time and attention from caregivers (P=0.016). Their most time-consuming daily needs were feeding (174 minutes) and support when they awoke at night (67 minutes). The average time that parents spent caring for their child was 8 hours and 54 minutes/day. It’s challenging, as clinicians, to care for children with complex health care needs, but it’s way harder to do it as a parent. Although medical appliances can help prolong a child’s life, they also substantially increase the daily burden of patient care that is largely borne by the family. Despite receiving care from a “centre of excellence” in Italy, the parents in this study spent more than half of their waking hours providing hands-on care to their children, impacting their relationships with their other children and each other.2 Less than half received outside help. It’s sobering to consider how much more these families would have struggled, were it not for the training and monitoring they did receive (and which, given the paucity of community-based pediatric palliative care services, many families are deprived of3). True family-centered care needs to take into consideration the family burden—and not merely the clinical benefit—of life-prolonging medical appliances. Robert C. Macauley, MD FAAPHM, Oregon Health and Science University, Portland, OR Lazzarin P, Schiavon B, Brugnaro L, Benini F. Parents spend an average of nine hours a day providing palliative care for children at home and need to maintain an average of five life-saving devices [published online ahead of print on September 25, 2017]. Acta Paediatr. doi: 10.1111/apa.14098. 1.McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics. 1998;102(1 pt 1):137–140.2.Epstein RH. Love, anger, and guilt: coping with a child’s chronic illness. New York Times. June 26, 2001. http://www.nytimes.com/2001/06/26/health/love-anger-and-guilt-coping-with-a-child-s-chronic-illness.html. Accessed December 28, 2017.3.Friebert S, Williams C. Pediatric palliative and hospice care in America. National Hospice and Palliative Care Organization, 2015. https://www.nhpco.org/sites/default/files/public/quality/Pediatric_Facts-Figures.pdf. Accessed December 28, 2017. Chemotherapy followed by hematopoietic stem-cell transplant (HCT) for patients with hematologic malignancies contributes to deterioration in quality of life (QOL) and mood.1-3 Can inpatient palliative care (PC) integrated with transplant care improve QOL and reduce psychological distress? This study (2014-2016) investigated the effect of inpatient PC integrated with transplant care on patient-reported psychological distress and QOL at 6 months posttransplant. Adult patients with hematologic malignancies who underwent HCT at Massachusetts General Hospital were assigned to inpatient PC (≥twice/week) integrated with transplant care or transplant care alone. Baseline and 6 month–posttransplant assessments included mood, posttraumatic stress disorder (PTSD) symptoms, and QOL using the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire (PHQ), PTSD checklist, and Functional Assessment of Cancer Therapy-Bone Marrow Transplant. The Edmonton Symptom Assessment Scale assessed symptom burden during HCT. Analysis included ANCOVA, mediation regression models, and Fisher’s exact test. Participants (79=control, 81=intervention) were mean age 57 (SD=13) years, 87% white, 57% female, 74% married, and 48% college educated. Between-group characteristics and baseline self-report measures did not differ. Intervention participants reported lower depression symptoms on the HADS (adjusted mean difference=−1.21, 95% CI=−2.26-−0.16; P=0.024) and PHQ (−1.63, 95% CI=−3.08-−0.19; P=.027) and lower PTSD symptoms (−4.02, 95% CI=−7.18-−0.86; P=.013), but there was no difference in fatigue, QOL, or anxiety. Symptom burden and anxiety during HCT hospitalization partially mediated the effect of the intervention on depression (B=0.06, standard error=0.02; P=.006 and B=0.29, 0.16; P=.014, respectively) and PTSD (B=0.12, 0.05; P=.008 and B=0.67, 0.25; P=.008, respectively) at 6 months. Despite a growing literature demonstrating the underutilization of palliative care for patients undergoing an HCT, collaborative efforts such as the one in this study have been on the rise. This article, one of a series from these investigators,7,8 demonstrates improved psychological symptoms when PC is provided. Importantly, inpatient PC involvement had positive psychological effects 6 months after the transplantation. The small sample size may even underestimate the intervention’s effect. Some programs have adopted symptom- or longevity-based triggers for PC consult either because of staffing issues or because of misplaced concerns that without a “reason” they can’t make an impact. This study shows integration is ideal to ameliorate the long-term effects of physical and psychological symptoms and promote better long-term health outcomes in patients who have undergone HCT. Short- and long-term clinical and psychological outcomes improve for patients who receive routine specialty palliative care in association with HCT. Monica L. Muir, DO, Washington University School of Medicine, St. Louis, MO; Jane E Loitman, MD MBA FAAHPM, Washington University School of Medicine, St. Louis, MO. El-Jawahri A, Traeger L, Greer JA, et al. Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: results of a randomized clinical trial. J Clin Oncol. 2017;35(32):3714-3721. 1.Braamse AM, Gerrits MM, van Meijel B, et al. Predictors of health-related quality of life in patients treated with auto- and allo-SCT for hematological malignancies. Bone Marrow Transplant. 2012;47(6):757–769.2.Curtis RE, Rowlings PA, Deeg HJ, et al. Solid cancers after bone marrow transplantation. N Engl J Med. 1997;336(13):897–904.3.Duell T, van Lint MT, Ljungman P, et al. Health and functional status of long-term survivors of bone marrow transplantation. EBMT Working Party on Late Effects and EULEP Study Group on Late Effects. European Group for Blood and Marrow Transplantation. Ann Intern Med. 1997;126(3):184–192.4.Chung HM, Lyckholm LJ, Smith TJ. Palliative care in BMT. Bone Marrow Transplant. 2009;43(4):265–273.5.Selvaggi KJ, Vick JB, Jessell SA, Lister J, Abrahm JL, Bernacki R. Bridging the gap: a palliative care consultation service in a hematological malignancy–bone Marrow Transplant Unit. J Community Support Oncol. 2014;12(2):50–55.6.Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Care Practice Guideline update. J Clin Oncol. 2017;35(1):96–112.7.El-Jawahri A, LeBlanc T, VanDusen H, et al. Effect of inpatient palliative care on quality of life 2 weeks after hematopoietic stem cell transplantation: a randomized clinical trial. JAMA. 2016;316(20):2094–2103.8.El-Jawahri A, Traeger L, Greer JA, et al. Effect of inpatient palliative care during hematopoietic stem-cell transplant on psychological distress 6 months after transplant: results of a randomized clinical trial. J Clin Oncol. 2017;35(32):3714–3721. The most common symptom in patients with cancer is cancer-related fatigue (CRF), which has limited treatment options.1-2 What are the effects of oral Panax ginseng extract (PG) on CRF? This study evaluated the effects of oral PG extract in patients with CRF. Patients with CRF ≥4/10 on the Edmonton Symptom Assessment System (ESAS) were enrolled from outpatient oncology centers and supportive care clinics at MD Anderson Cancer Center. Patients received 400 mg of PG twice/day or placebo for 28 days. The primary end-point was change in the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) subscale. Secondary measures were quality of life, mood, and function. Analysis included χ2, t-tests, the Fisher exact test, multiple linear modeling, and the Shapiro-Wilk statistic. Participants (56=placebo, 56=PG) were median age 61 (IQR=54-67) years, were 42% female, were 81% white; and had median 14 (IQR=12-16) years education 98% of participants had advanced cancer. No group differences were seen in baseline characteristics, except cancer type (P=0.01): in placebo and PG groups, respectively, 11% and 24% had breast cancer and 73% and 49% had genitourinary cancer. There was improvement in mean FACIT-F and ESAS fatigue scores for both groups at days 15 and 29 (P<0.001). Mean improvements in ESAS-Fatigue, FACIT-F, Hospital Anxiety and Depression Scale, ESAS, 6-minute walk test, and hand grip strength scores at day 29 were not different between groups. The frequency of a Global Symptom Evaluation score of “better” was not different between groups. Higher fatigue (P=0.0005), depression (P=0.032), and male sex (P=0.023) were associated with greater CRF improvement. A Chinese group also completed a similar trial this year with positive results.3 These two studies used different doses of PG (800 mg/day vs. 3,000 mg/day), had different timeframes (1 month vs. 2 months), and used different fatigue instruments. Patients in the Chinese study were undergoing chemotherapy. There are two positive American trials using Panax quinequefolius.4,5 One study was a dose-finding trial that compared different doses of Panax quinequefolius to placebo, and the second study randomized patient between placebo and 2,000 mg/day of Panax quinequefolius. The timeframe was 2 months and different fatigue instruments were used than in the present study. Importantly, in addition to these study variances, there are significant differences in ginsenosides between studies. Panax quinequefolius contains 3-6 fold greater Rb1 ginsenoside.6 The Chinese study made up the difference by increasing the PG dose 3- to 4-fold. Rb1 is known to be neuroprotective, which perhaps is the reason for ginseng’s fatigue benefits.7 Low-dose PG does not improve cancer-related fatigue. Mellar P. Davis, MD FCCP FAAHPM, Geisinger Medical Center, Danville, PA. Yennurajalingam S, Tannir NM, Williams JL, et al. A double-blind, randomized, placebo-controlled trial of Panax ginseng for cancer-related fatigue in patients with advanced cancer. J Natl Compr Canc Netw. 2017;15(9):1111-1120. 1.Berger AM, Mooney K, Banerjoo C, et al. NCCN clinical practice guidelines in oncology: cancer-related fatigue, version 1.2016. Published December 1, 2015. Accessed July 27, 2017.2.de Raaf PJ, de Klerk C, Timman R, Hinz A, van der Rijt CC. Differences in fatigue experiences among patients with advanced cancer, cancer survivors, and the general population. J Pain Symptom Manage. 2012;44(6):823–830.3.Jiang SL, Liu HJ, Liu ZC, et al. Adjuvant effects of fermented red ginseng extract on advanced non-small cell lung cancer patients treated with chemotherapy. Chin J Integr Med. 2017;23(5):331–337.4.Barton DL, Liu H, Dakhil SR, Linquist B, et al. Wisconsin Ginseng (Panax quinquefolius) to improve cancer-related fatigue: a randomized, double-blind trial, N07C2. J Natl Cancer Inst. 2013;105(16):1230–1238.5.Barton DL, Soori GS, Bauer BA, et al. Pilot study of Panax quinquefolius (American ginseng) to improve cancer-related fatigue: a randomized, double-blind, dose-finding evaluation: NCCTG trial N03CA. Support Care Cancer. 2010;18(2):179–187.6.Chen CF, Chiou WF, Zhang JT. Comparison of the pharmacological effects of Panax ginseng and Panax quinquefolium. Acta Pharmacol Sin. 2008;29(9):1103–1108.7.Ahmed T, Raza SH, Maryam A, et al. Ginsenoside Rb1 as a neuroprotective agent: a review. Brain Res Bull. 2016;125:30–43. We appreciate your feedback. Help us help you—send your comments to [email protected] PC-FACS was created in 2005 by Founding Editor-in-Chief Amy P. Abernethy, MD, PhD, FACP, FAAHPM. The Academy is deeply grateful to Dr. Abernethy for creating this important publication and for her many contributions to the field of hospice and palliative medicine. PC-FACS is edited by Editor-in-Chief, Mellar P. Davis, MD, FCCP, FAAHPM, of the Geisinger Health System, and Associate Editor-in-Chief, Robert M. Arnold, MD, FAAHPM, of the University of Pittsburgh Medical Center. All critical summaries are written by Jeff Fortin, MD. AAHPM thanks the following PC-FACS Editorial Board members for their review of the critical summaries and preparation of the commentaries: Editorial Leadership Mellar P. Davis, MD, FCCP, FAAHPM, Editor-in-Chief Robert M. Arnold, MD, FAAHPM, Associate Editor-in-Chief Basic Science Eric Roeland, MD, FAAHPM, Senior Section Editor Amy L. Davis, DO, MS, FACP, FAAHPM Rony Dev, DO, MS Rosene Pirrello, RPh Jacob Strand, MD Bioethics, Humanities, and Spirituality Francine Rainone, DO, PhD, MS, FAAHPM, Senior Section Editor Hunter Groninger, MD, FAAHPM Adam Marks, MD Jessica A. Moore, DHCE, MA Erin Zahradnik, MD Geriatrics and Care Transitions Eric Widera, MD, FAAHPM, Senior Section Editor Gouri Bhattacharyya, MD, MRCP David B. Brecher, MD, FAAFP, FAAHPM Elizabeth Chuang, MD, MPH Marissa Galicia-Castillo, MD, MSEd, CMD, FACP, FAAHPM Hospice, Hospice and Palliative Medicine Interface, and Regulatory Issues Joel S. Policzer, MD, FACP, FAAHPM, Senior Section Editor Christopher Jones, MD, FAAHPM Matthew G. Kestenbaum, MD, FAAHPM Nina O'Connor, MD Renato Samala, MD, FACP Pediatrics Christina Ullrich, MD, MPH, FAAHPM, Senior Section Editor Christopher A. Collura, MD Robert C. Macauley, MD, FAAP, FAAHPM Kevin Madden, MD Rachel Thienprayoon, MD Psychosocial Ronit Elk, PhD, Senior Section Editor Myra Glajchen, DSW Jane E. Loitman, MD, MBA, FAAHPM Karen Ogle, MD, FAAHPM Abby R. Rosenberg, MD, MS, FAAP Symptom Assessment and Management Marcin Chwistek, MD, FAAHPM, Senior Section Editor James T. D'Olimpio, MD, FACP, FAAHPM Giovanni Elia, MD, FAAHPM Meaghann Shaw Weaver, MD, MPH Jason A. Webb, MD Medical Writers Jeff M. Fortin, PhD (September 2016-present) Lana Christian, MS (August 2015-August 2016) Moses Sandrof (October 2014-July 2015) Jane Wheeler (July 2005-September 2014) AAHPM Staff Laura Davis, CAE, Director, Marketing and Membership Allison Lundberg, Manager, Marketing and Membership Andie Bernard, Managing Editor AAHPM Publications Committee (Joanne Wolfe, MD, chair) The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 8735 W. Higgins Road, Suite 300 Chicago, IL 60631, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: Website: www.aahpm.org
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