Portal de Periódicos da CAPES

February PC-FACS

2022; Elsevier BV; Volume: 63; Issue: 4 Linguagem: Inglês

10.1016/j.jpainsymman.2022.02.005

1873-6513

Andie Bernard,

Oral health in cancer treatment

February 1, 2022 Bile Acid Metabolism for Cancer Cachexia Spirituality in Palliative Care Educating Clinicians on LGBT+ Needs Geriatric and Palliative Care Consultation In-Home Services at the End of Life Parent-Reported Outcomes Medical Cannabis for Chronic Pain Rave Reviews Association of Bile Acid Metabolism With Treating Cancer Cachexia Background: Cancer cachexia (CC) afflicts approximately 50%–80% of advanced cancer patients.1 What is the role of bile acid (BA) metabolism in CC? Design and Participants: This study investigated how liver and gut microbiota contribute to BA metabolism disturbance in CC and explored the possibility of targeting BA metabolism using tauroursodeoxycholic acid (TUDCA) for CC therapy. BA profiles in the liver, intestine, and serum of CC mice were analyzed using metabolomics methods and compared against control mice. Liver tissue and gut microbiota protein expression were analyzed using proteomic analysis and 16S rRNA gene sequencing, respectively. RT-PCR analyzed gene expression related to the farnesoid X receptor (FXR) signaling pathway, an important mediator in the gut-liver axis, in the intestine and liver tissues. Subsequently, clinical colon cancer patients’ serum BA profiles were analyzed. Finally, TUDCA was tested in CC mice. ANOVAs and t-tests were used. Results: In CC mice, liver BA synthesis enzyme expression was inhibited while total BA amounts increased and the conjugated/unconjugated BA ratio increased. Gut microbiota dysbiosis was observed, and microbial metabolism of BAs was reduced. FXR pathway activation possibly contributed to regulation of BA synthesis enzymes, transporters, and metabolic enzymes. Increased serum BA conjugation was also observed. Clinically, the serum level of total unconjugated BAs in mice with cancer without cachexia was lower than healthy mice but higher in CC mice versus mice with cancer without cachexia, indicating a possible compensatory response in the development of cachexia. TUDCA ameliorated mouse body weight loss, muscle loss, and heart and liver atrophy without influencing tumor growth (all P < 0.05). Commentary: CC is widely prevalent among patients with cancer, and it can be devastating. Altered hepatobiliary function has garnered increasing attention as a mechanism for CC. Several murine models have demonstrated that bile flow and hepatobiliary transport function are impaired in mice with CC.2–3 The work of Feng et al augments these findings by confirming that both lipid and BA metabolism are altered in CC and highlighting a signaling pathway that could potentially be targeted by future therapeutics. They also suggest that oral supplementation of a conjugated BA such as TUDCA can mitigate CC in mice, a finding supported by other studies.4 Their model and statistical methodology appears sound, and their findings raise promising avenues for future evaluation in human models. Bottom Line: Interventions targeting hepatobiliary metabolism pathways may present a promising pathway for treating CC. Reviewer: Rachel Hadler, MD, University of Iowa Hospital and Clinics, Iowa City, IA References:1.Brown J, Rosa-Caldwell ME, Lee DE, et al. Mitochondrial degeneration precedes the development of muscle atrophy in progression of cancer cachexia in tumor-bearing mice. J Cachexia Sarcopenia Muscle. 2017;8(6):926–938. doi:10.1002/jcsm.122322.Thibaut MM, Gillard J, Dolly A, et al. Bile acid dysregulation is intrinsically related to cachexia in tumor-bearing mice. Cancers (Basel). 202l;13(24):6389. doi:10.3390/cancers132463893.Thibaut MM, Sboarina M, Roumain M, et al. Inflammation-induced cholestasis in cancer cachexia. J Cachexia Sarcopenia Muscle. 2021;12(1):70–90. doi:10.1002/jcsm.126524.Tschirner A, von Haehling S, Palus S, Doehner W, Anker SD, Springer J. Ursodeoxycholic acid treatment in a rat model of cancer cachexia. J Cachexia Sarcopenia Muscle. 2012;3(1):31–36. doi:10.1007/s13539-011-0044-4 Source: Feng L, Zhang W, Shen Q, et al. Bile acid metabolism dysregulation associates with cancer cachexia: roles of liver and gut microbiome. J Cachexia Sarcopenia Muscle. 2021;12(6):1553–1569. doi:10.1002/jcsm.12798 Access this article on PubMed. Enhancing Palliative Care Clinicians’ Skills for Discussing Spirituality in Serious Illness Background: Most people with serious illness indicate the importance and helpfulness of religion and spirituality (R/S).1–3 How can medical providers recognize patients’ spiritual and religious pain? Design and Participants: This article described tips to enhance palliative care (PC) clinicians’ skills while offering guidance for screening for spiritual distress (SD) and an overview of partnering with interprofessional colleagues to heal SD and ensure patients receive values-aligned spiritual care. Results: Tips include: 1) Use the communication tools you have already mastered (responding to challenging emotions, delivering bad news, providing medical care with cultural humility/sensitivity); 2) Repeatedly screen all patients for SD; 3) Many patients want you to ask about R/S, and taking an R/S history is a way to do that (FICA4); 4) Though any team member can screen for SD and uncover R/S needs and resources, chaplains are experts at doing so; 5) R/S factor into advance care planning, so clinicians should ask patients and families about the role of faith in their decision making; 6) If patients and families mention they believe in miracles, this can be used to segue into goals of care discussions (rather than seeing it as a rejection of science and medicine); 7) If patients ask if you are spiritual or religious, you can give a general statement affirming your care and your desire to hear what is important to them; 8) It is not required that you tell a patient you are making a chaplain referral; 9) Listen for key words, phrases, and themes (e.g., deferring control to God/karma) as prompts for chaplain referral; 10) Be sensitive and humble regarding domains impacted by cultural, religious, and spiritual backgrounds (e.g., nutrition, medication/treatments, modesty, ritual objects, religious garb, holy days, decision making). Commentary: Although most clinicians agree that addressing SD is a core aspect of PC, many do not feel comfortable exploring spiritual concerns with their patients. Most studies indicate that the two most common reasons clinicians are reluctant to explore spiritual concerns are lack of training and lack of time. Therefore, it is critical that PC include specific training, such as the recently developed Interprofessional Spiritual Care Education Curriculum (ISPEC), for spiritual issues. The training helps integrate spiritual care into clinical care in a time-effective manner. PC clinicians are already familiar with high-quality communication, interdisciplinary care and an inquisitive approach to understanding a patient's experience are familiar concepts. With additional training on how to assess for spiritual distress and spiritual well-being and how to work with chaplains on attending to the spiritual needs for patients, more clinicians will be able to integrate spiritual care in their practice. Bottom Line: Many PC providers feel uncomfortable asking about spiritual concerns; however, they already have many of the skills necessary to identify SD. They must hone these skills to ensure they are meeting patient needs. Reviewer: Kate Lally, MD FAAHPM, Dana Farber Cancer Institute, Boston, MA References:1.Sulmasy DP. The Rebirth of the Clinic: An Introduction to Spirituality in Health Care. Washington, DC: Georgetown University Press; 2006.2.Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol. 2007;25(5):555–560. doi:10. 1200/JCO.2006.07.90463.Canada AL, Fitchett G, Murphy PE, et al. Racial/ethnic differences in spiritual well-being among cancer survivors. J Behav Med. 2013;36(5):441–453. doi:10.1007/s10865-012-9439-84.Borneman T, Ferrell B, Puchalski CM. Evaluation of the FICA tool for spiritual assessment. J Pain Symptom Manage. 2010;40(2):163–173. doi:10.1016/j.jpainsymman.2009.12.019 Source: Kestenbaum A, Fitchett G, Galchutt P, et al. Top ten tips palliative care clinicians should know about spirituality in serious illness [published online ahead of print December 6, 2021]. J Palliat Med. doi:10.1089/jpm.2021.0522 Access this article on PubMed. Development and Evaluation of an LGBT+ Education Program for Palliative Care Interdisciplinary Teams Background: Discrimination and marginalization based on sexual orientation and gender identity affects the health and well-being of many LGBT+ people.1–4 How can education on LGBT+ issues and needs be improved in health and social care curricula? Design and Participants: This project, across four hospices, introduced training for palliative and end-of-life care (PC+EOLC) teams to better provide LGBT+ affirmative care for people receiving and needing PC + EOLC. A 1.5-hour workshop was developed and evaluated using Kotter's eight-step process for leading change. A quasi-experimental nonequivalent groups pretest-posttest design measured self-reported levels of knowledge, confidence, and comfort with issues related to LGBT + and PC. Age was collapsed into two categories: 18–49 years and older than 50 years. Self-reported ratings before and after training were compared within and between age groups. Descriptive statistics, chi-square, and the Wilcoxon signed-rank test were used. Results: Participants (N = 145) were 39% nurses, 16% counsellors, and 15% healthcare assistants. Ninety-four percent reported female gender, 97% reported heterosexual orientation, and 90% reported Caucasian/white ethnicity. There was an increase in knowledge of general LGBT+ issues and needs (Z = -9.135), knowledge of LGBT+ issues and needs in PC+EOLC (Z=-10.019), confidence in providing PC + EOLC for LGBT+ people (Z = -7.957), and comfort with gender- and sexual identity–related terminology (Z=-3.699) (all P < 0.001). Knowledge, confidence, and comfort improved posttraining within both age groups. Knowledge of LGBT+ issues and needs in PC+EOLC was higher pretraining among people older than 50 years than 18–49-year-olds (χ2 = 7.364, df = 2, P < 0.05). Seventy-nine percent rated the training as excellent, 100% would recommend it, 99% reported it as useful, and 95% were interested in further training. Commentary: This is an important study that analyzed the benefits of an educational workshop for interdisciplinary teams to improve understanding of the LGBT + population's needs. By demonstrating a significant increase in reported levels of knowledge, confidence, and comfort with LGBT + needs and terminology, this study provides evidence of the importance of such training. Lack of such training can lead to delays in diagnosis and treatment, barriers in advance care planning, and inadequate bereavement support, all of which may contribute to preventable suffering and undermine trust in clinicians. Because this study took place in England (where both health care and LGBTQ+ culture may be distinct); replication studies in the United States would be valuable. Bottom Line: Educating clinicians on LGBT + needs is feasible and acceptable and may improve quality care delivery. Reviewer: Mona Patel Kathuria, DO FAAHPM, New Jersey Veterans Affairs Health Care System, East Orange and Lyons, NJ References:1.Almack K. Dying, death and bereavement. In: Goldberg A, ed. The SAGE Encyclopedia of LGBTQ Studies. New York, NY: SAGE; 2016:342–347.2.Government Equalities Office. LGBT action plan: improving the lives of lesbian, gay, bisexual and transgender people. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/721367/GEO-LGBT-Action-Plan.pdf. Published July 2018. Accessed January 25, 2022.3.Elliott MN, Kanouse DE, Burkhart Q, et al. Sexual minorities in England have poorer health and worse health care experiences: a national survey. J Gen Intern Med. 2015;30(1):9–16. doi:10.1007/s11606-014-2905-y4.Bristowe K, Hodson M, Wee B, et al. Recommendations to reduce inequalities for LGBT people facing advanced illness: ACCESSCare national qualitative interview study. Palliat Med. 2018;32(1): 23–35. doi:10.1177/0269216317705102 Source: Chidiac C, Grayson K, Almack K. Development and evaluation of an LGBT + education programme for palliative care interdisciplinary teams. Palliat Care Soc Pract. 2021;15:26323524211051388. doi:10.1177/26323524211051388 Access this article on PubMed. Interprofessional Geriatric and Palliative Care Intervention Associated With Fewer Hospital Days Background: With the increasing complexity of the aging inpatient population, attention to length of stay, readmissions, and daily resource utilization is paramount.1–4 Can a geriatric and palliative care (PC) intervention improve outcomes? Design and Participants: This study implemented an interprofessional geriatric and PC, nonrandomized controlled intervention and measured its impact on outcomes for adults admitted to a general medicine hospitalist service at a 1000-bed academic quaternary medical center. On two of 11 hospitalist teams (intervention), a geriatrician, PC physician, and social worker attended multidisciplinary discharge rounds twice weekly and made informal recommendations ranging from pursuing formal inpatient geriatric and palliative care consultation (GPCC) to post-acute care location and postdischarge outpatient consultation. The hospitalists made the final decision about whether to request an inpatient consult. Usual care (nine control teams) consisted of multidisciplinary discharge rounds with the hospitalist and case manager daily to discuss patients and their discharge needs. Improvements (intervention vs. concurrent control teams) were measured for the following: length of stay adjusted for case-mix index, 30-day readmissions, and hospital service utilization intensity (mean services per patient per day). Difference-in-differences analysis and generalized linear model regression were used. Results: Of 13,941 patients, 5644 were age greater than 65 years; 1483 were on intervention teams (576 age greater than 65 years), 5413 were on control teams, and 7045 were historical controls (baseline period). Length of stay decreased mean = 0.36 days (P = 0.039) for intervention teams (net = 529 days saved [95% CI = 112–1,073]), with greater reduction of mean = 0.55 days (P = 0.022) among the 576 older patients (net = 315 [76–606]). Readmissions were unchanged (-1.17%, P = 0.48; 1.91%, P = 0.46 for older patients). However, daily relative value unit (RVU) utilization increased overall and for the older subgroup (mean=0.35 RVUs per patient-day, P = 0.041; mean = 0.74 RVUs, P < 0.001 for older patients) per patient-day on average across the intervention teams. Commentary: Many geriatrics and palliative care (GPC) clinicians recognize the importance of attending interdisciplinary rounds. Previous data suggest PC involvement on intensive care unit rounds shortens hospital length of stay.5 In this study, a geriatrician, PC physician, and social worker attended the multidisciplinary discharge rounds in collaboration with a hospitalist service twice weekly at a large academic medical center with both geriatrics and PC consultation service lines, resulting in decreased length of stay and a modest increase in utilization. This study finding again makes the case for proactive GPC involvement in hospitalized older adults. Further research is warranted to evaluate the effect of GPCC with respect to adherence to consultation recommendations and transition of care for patients who received a consultation. Bottom Line: GPC team attendance in multidisciplinary discharge planning rounds decreased length of stay in adult patients without increasing 30-day readmissions. Reviewer: Yuya Hagiwara, MD MACM, University of Iowa Carver College of Medicine, Iowa City, IA References:1.Kuo Y-F, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360(11):1102–1112. doi:10.1056/NEJMsa08023812.Kuo Y-F, Goodwin JS. Effect of hospitalists on length of stay in the Medicare population: variation according to hospital and patient characteristics. J Am Geriatr Soc. 2010;58(9):1649–1657. doi:10.1111/j.1532-5415.2010.03007.x3.Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;2016(1):CD000313. doi:10.1002/14651858.CD000313.pub54.Ortiga B, Salazar A, Jovell A, Escarrabill J, Marca G, Corbella X. Standardizing admission and discharge processes to improve patient flow: a cross sectional study. BMC Health Serv Res. 2012;12(1):180. doi:10.1186/1472-6963-12-1805.Braus N, Campbell TC, Kwekkeboom KL, et al. Prospective study of a proactive palliative care rounding intervention in a medical ICU. Intensive Care Med. 2016;42(1):54–62. doi:10.1007/s00134-015-4098-1 Source: Min L, Saul D, Firn J, Chang R, Wiggins J, Khateeb R. Interprofessional geriatric and palliative care intervention associated with fewer hospital days [published online ahead of print November 9, 2021]. J Am Geriatr Soc. doi:10.1111/jgs.17545 Access this article on PubMed. Association of the Frequency of In-Home Care Services Utilization and the Probability of In-Home Death in Japan Background: Although 55% of the Japanese population age greater than 55 years prefer in-home death, few (13% in 2017) experience in-home death (versus Canada [60%], England [46%], and the United States [31%]).1–3 Do in-home care services enable recipients to stay home at the end of life? Design and Participants: This retrospective cohort study of older adults in Japan's long-term care insurance system used national claims data to assess whether in-home care services allow patients to stay home at the end of life. Participants were long-term care insurance beneficiaries age greater than 65 years who died in 2015, excluding those who died from external causes (e.g., accidents). Frequency of in-home care service use was defined as the mean days of in-home care services used per week from the first day of the month before the month of death to the date of death. The primary outcome was whether participants died in their home. Lack of information on individual preference for place of death was addressed using an instrumental variable estimation with the full-time equivalent number of care workers providing in-home care services per older population at the municipality level in 2014. Analyses included ordinary and two-stage least squares regression, Kleibergen-Paap Wald rk F statistic, Wooldridge's robust score test, and the robust regression-based F-test. Results: Decedents (N = 572,059) were 55% women (aged median = 87 years [IQR = 81–91]). The proportion of in-home deaths was 11%, and 14% used in-home care services at least once. Each day of increase in in-home care service use was associated with a 3.6 and 5.0 percentage point increased probability of in-home death (two-stage least squares estimate [95% CI = 2.3–4.9] and ordinary least squares [4.9–5.1], respectively). Commentary: Prior studies have demonstrated that in-home services at the end-of-life support in-home deaths.4–6 This study adds support for more frequent services. This finding is limited by the characteristics of the patient and in-home services. Patients with cancer who are married and need less care benefited from frequent in-home services. For patients with greater care needs and less support at home, these services may not be enough. In addition, in-home services available in Japan, where this study was conducted, vary from those available in other countries. Given homecare's structural differences, implementation of this study's findings is probably not generalizable within most healthcare systems. Bottom Line: Providing in-home services more frequently is more likely to allow for more desired home deaths, but this may not be practical for all patients or applicable within all healthcare systems. Reviewer: Ambereen K. Mehta, MD MPH, Johns Hopkins Bayview Medical Center, Baltimore, MD References:1.Japanese Ministry of Health Labour and Welfare. The results of the survey on awareness of the elderly people about their health. https://www.mhlw.go.jp/file/05-Shingikai-10801000-Iseikyoku-Soumuka/0000200749.pdf. Published 2017. Accessed April 19, 2021.2.Cross SH, Warraich HJ. Changes in the place of death in the United States. N Engl J Med. 2019;381(24):2369–2370. doi:10.1056/NEJMc19118923.Japanese Ministry of Health Labor and Welfare. Trends in percent distribution of deaths by place of occurrence. Data sheet in Japanese. https://www.e-stat.go.jp/stat-search/file-download?statInfId=000032020123&fileKind=1. Accessed April 19, 2021.4.Gomes B, Higginson IJ. Factors influencing death at home in terminally ill patients with cancer: systematic review. BMJ. 2006;332(7540):515–521. doi:10.1136/bmj.38740.614954.555.Abe K, Miyawaki A, Kobayashi Y, Watanabe T, Tamiya N. Place of death associated with types of long-term care services near the end-of-life for home-dwelling older people in Japan: a pooled cross-sectional study. BMC Palliat Care. 2020;19(1):121. doi:10.1186/s12904-020-00622-06.Abe K, Miyawaki A, Kobayashi Y, Noguchi H, Takahashi H, Tamiya N. Receiving the home care service offered by certified care workers prior to a patients’ death and the probability of a home death: observational research using an instrumental variable method from Japan. BMJ Open. 2019;9(8):e026238. doi:10.1136/bmjopen-2018-026238 Source: Abe K, Kawachi I, Watanabe T, Tamiya N. Association of the frequency of in-home care services utilization and the probability of in-home death. JAMA Netw Open. 2021;4(11):e2132787. doi: 10.1001/jamanetworkopen.2021.32787 Access this article on PubMed. Parent Perceptions of Infant Symptoms and Suffering and Associations With Distress Among Bereaved Parents in the NICU Background: When infants spend their lives in the neonatal intensive care unit (NICU), hindering parent-child bonding, a main stressor for parents is disruption of expected parenting roles.1–2 What are parents’ perceptions of infant symptoms and suffering at the end of life? Design and Participants: This cross-sectional pilot study explored associations between parental perceptions of infant end-of-life symptoms and suffering and parent adjustment following death. Parents of infants who died within the previous five years in a large Midwestern, level IV NICU were recruited. Parents retrospectively reported on infant symptom burden and suffering during the last week of life and completed the Impact of Event Scale-Revised (IES-R), which evaluates posttraumatic stress symptoms (PTSS), and prolonged grief (PG)-13. Descriptive statistics and t-tests were used, and hierarchical regressions examined demographic and medical factors and parent perceptions in relation to PTSS and PG. Results: Forty mothers (age mean = 33 years [SD = 6.0], 88% white) and 27 fathers (mean = 37 years [SD = 9.5], 58%) represented 40 infants (mean = 5.0 weeks [SD=5.9, range = 1 day–24 weeks]). Overall, 78% completed some postsecondary education (mean = $50,000–75,000/year family income). Surveys were collected at mean = 39 months postdeath (SD = 17, range = 3 months–5 years). Eighteen percent of mothers and 11% of fathers exceeded PTSS clinical cutoff, and 3% of mothers and fathers exceeded PG cutoff. When both parents responded (n = 27), there was no difference between average mother and father PG scores and IES-R scores. There was also no difference between mother and father average report of infant total symptoms or perceptions of infant suffering. Maternal perception of higher symptom burden was associated with greater PTSS (R2 = 0.46, P = 0.001) and PG (R2=0.47, P < 0.01). Paternal perception of greater infant suffering was associated with greater PTSS (R2 = 0.48, P = 0.001) and PG (R2 = 0.38, P < 0.01). Commentary: This cross-sectional study of bereaved parents of neonates demonstrates how parental perceptions of symptoms and suffering at the end-of-life may affect bereavement. It also identifies socioeconomic status, education, and parental gender as factors that should be further studied and potentially integrated into screening for risk of complicated bereavement. However, the most intriguing finding is that parental reports of symptom burden differed from the medical record, and only parent reports correlated with parent distress. This demonstrates the importance of integrating parent-reported outcomes in documentation, research, and decision making. The next question is, if clinicians proactively address parental concerns related to symptoms and suffering at the end of life, can it decrease parental distress during bereavement? This work creates a foundation (and motivation) to answer these questions. Bottom Line: Parental perceptions of symptoms and suffering are associated with parental distress during bereavement. Parent-reported outcomes may help clinicians better identify parents at risk for complicated bereavement. Reviewer: Scott H. Maurer, MD, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA References:1.Fortney CA, Steward DK. A new framework to evaluate the quality of a neonatal death. Death Stud. 2014;38(1–5):294–301. doi:10.1080/07481187.2012.7424752.Currie ER, Christian BJ, Hinds PS, et al. Parent perspectives of neonatal intensive care at the end-of-life. J Pediatr Nurs. 2016;31(5):478–489. doi:10.1016/j.pedn.2016.03.023 Source: Clark OE, Fortney CA, Dunnells ZDO, Gerhardt CA, Baughcum AE. Parent perceptions of infant symptoms and suffering and associations with distress among bereaved parents in the NICU. J Pain Symptom Manage. 2021;62(3):e20–e27. doi:10.1016/j.jpainsymman.2021.02.015 Access this article on PubMed. Medical Cannabis for Chronic Noncancer and Cancer-Related Pain Background: The shift away from the use of long-term opioids for chronic pain has raised interest in cannabis as an alternative.1–2 How effective is medical cannabis (MC) for chronic pain? Design and Participants: This review determined the benefits and harms of MC for chronic pain. Included trials enrolled at least 20 patients who had chronic pain lasting at least three months, randomized them to MC/cannabinoids versus placebo or active comparator, and followed them for at least one month. Paired reviewers independently assessed risk of bias. Random-effects models meta-analyzes were performed, and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)3–4 assessed certainty of evidence. Results: Thirty-two trials (5,174 adults; range = 1–5.5 months follow-up) were included (28 chronic pain and four cancer pain). MC was administered orally (noninhaled; n = 30) or topically (n = 2). Noninhaled MC yielded: a small increase in the proportion of patients experiencing the at least 1 cm minimally important difference (MID) (10 cm visual analogue scale [VAS]) in pain relief (modelled risk difference [RD] of 10% [95% CI = 5%–15%], based on a -0.50 cm weighted mean difference (WMD) [-0.75–-0.25 cm, moderate certainty]); oral MC results in very small physical functioning improvement (4% modelled RD [0.1%–8%] for achieving the at least 10-point MID on the 100-point SF-36 physical functioning scale, 1.7-point WMD [0.03–3.3, high certainty]); a small sleep quality improvement (6% modelled RD [2%–9%] for achieving the at least 1 cm MID (10 cm VAS), -0.35 cm WMD [-0.55–-0.14 cm, high certainty]); no emotional, role, or social functioning improvement (high certainty). Side effects for oral MC included a small increased risk of transient cognitive impairment (RD 2% [0.1%–6%]), vomiting (RD 3% [0.4%–6%]), drowsiness (RD 5% [2%–8%]), impaired attention (RD 3% [1%–8%]), and nausea (RD 5% [2–8%]), but not diarrhea (moderate certainty). Side effects also included an increased dizziness risk (RD 9% [5%–14%]) for trials with follow ups less than 3 months versus at or after three months (RD 28% [18%–43%]) (high certainty). Commentary: This systematic review and meta-analysis was guided by a panel of experts and patient representatives to contextualize MC usage and impact. Often, palliative care providers are challenged to treat pain without using opiates, either due to medical contraindications or a patient's preference. This study provides evidence suggesting that the use of MC may provide small improvement in chronic pain, physical function, and sleep quality. It also provides a list of adverse effects after using oral MC for 1–3 months, including cognitive impairment, impaired attention, vomiting, nausea, and drowsiness. If oral MC is used for more than 3 months, there is a high chance of developing dizziness. No adverse effects were reported with topical MC. Bottom Line: MC could be considered as an alternative for nonopioid treatment of chronic cancer and noncancer related pain. The potential for developing dizziness and cognitive impairment may limit its use in elderly patients. Reviewer: Dulce M. Cruz, MD FAAHPM AGSF, Section of Palliative Medicine, Division of General Internal Medicine Department of Medicine, Johns Hopkins Hospital, Baltimore, MD References:1.Amato L, Minozzi S, Mitrova Z, et al. Systematic review of safeness and therapeutic efficacy of cannabis in patients with multiple sclerosis, neuropathic pain, and in oncological patients treated with chemotherapy. Epidemiol Prev. 2017;41(5–6):279–293. doi:10.19191/EP17.5-6.AD01.0692.Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: a review. Drug Alcohol Depend. 2017;177:1–13. doi:10.1016/j.drugalcdep.2017.03.0093.3.Guyatt GH, Juniper EF, Walter SD, Griffith LE, Goldstein RS. Interpreting treatment effects in randomized trials. BMJ. 1998;316(7132):690–693. doi:10.1136/bmj.316.7132.6904.Santesso N, Glenton C, Dahm P, et al. GRADE guidelines 26: informative statements to communicate the findings of systematic reviews of interventions. J Clin Epidemiol. 2020;119:126–135. doi:10.1016/j.jclinepi.2019.10.014 Source: Wang L, Hong PJ, May C, et al. Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomized clinical trials. BMJ. 2021;374:n1034. doi:10.1136/bmj.n1034 Access this article on PubMed. Rave Reviews Devanand DP, Crocco E, Forester BP, et al. Low dose lithium treatment of behavioral complications in Alzheimer's disease: lit-AD randomized clinical trial. Am J Geriatr Psychiatry. 2022;30(1):32–42. doi:10.1016/j.jagp.2021.04.014 Until this point, lithium has not been formally studied as a pharmacological intervention for behavioral symptoms of late-stage Alzheimer's disease (AD). This randomized controlled trial looked at low-dose lithium effectiveness and safety for agitation and aggression symptoms. Though lithium proved very safe in these patients, there was no significant change in agitation; however, some patients did show reduced manic symptoms. This may indicate that a specific subgroup of agitated AD patients could benefit from lithium. Zamora EBC, Romera MM, Sahuquillo MTT, et al. Psychological and functional impact of COVID-19 in long-term care facilities: the COVID-A study. Am J Geriatr Psychiatry. 2022. Residents of long-term care facilities have had a particularly harrowing and stressful course during the pandemic. This study investigated the psychological effects of COVID-19 in older adults living in such situations. There was a high burden of posttraumatic stress disorder, depression, and anxiety symptoms at baseline during early pandemic and a significantly higher amount found among patients who had tested positive for COVID-19. Essentially all patients, despite COVID-19 status, showed functional decline during this time. Reasons are unclear, though it may be related to extreme social isolation. Chen Z, Ding Z, Chen C, et al. Effectiveness of comprehensive geriatric assessment intervention on quality of life, caregiver burden and length of hospital stay: a systematic review and meta-analysis of randomized controlled trials. BMC Geriatr. 2021;21(1):377. doi:10.1186/s12877-021-02319-2 Comprehensive geriatric assessments (CGAs) are used in older adult patients to determine functional ability in order to improve it and reduce mortality. This meta-analysis looked at the potential additional effects of CGAs on patient quality of life, caregiver burden, and length of hospital stays. It found that though there was no change in length of hospital stay, there were significant improvements in quality of life and reduction of caregiver burden among patients who had CGAs.