Journal of pain and symptom management最新文献

Context: Corticosteroids are frequently used for cancer-related neuropathic pain. However, the evidence for their efficacy is limited.

Objectives: The purpose of this study was to identify factors that may indicate the efficacy of corticosteroids for cancer-related neuropathic pain.

Methods: This study was prospective multicenter observational and non-randomized cohort study with no placebo arm. Participants were recruited from 17 palliative care departments in Japan. All participants were thought to have cancer-related neuropathic pain and reported pain scores before and 7 days after corticosteroid administration. The primary outcome was the worst pain score in the last 24 hours. The secondary outcomes were Personalized Pain Goal and Patient Global Impression of Change. The multivariate logistic regression model was used to identify factors for cancer-related neuropathic pain by corticosteroid administration.

Results: A total of 97 participants were included in this study. Among the 97 participants, 50 achieved pain relief and 47 reported no pain relief. The multiple logistic regression model showed that normal white blood cell count (≤ 8500/µL) (p = 0.0049), low Karnofsky Performance Scale score (≤ 40) (p = 0.0080), and intracranial tumor as the origin of pain (p = 0.082) were factors related to relief of cancer-related neuropathic pain by corticosteroid administration.

Conclusion: This study identified intracranial tumor, low Karnofsky Performance Scale, and normal WBC count as factors that may predict effectiveness of cancer-related neuropathic pain by corticosteroid administration.

Context: Patients with stage IV cancer often experience multiple, sequential symptoms that can co-exist, interact and negatively impact health-related quality of life. Currently, it is challenging to identify patients at risk of developing high symptom burden.

Objective: To identify subgroups of patients with distinct symptom burden trajectories and characteristics of patients at risk of developing high symptom burden.

Methods: We pooled data from two prospective studies, using the EORTC QLQ-C30 to assess symptom burden at baseline, 3, 6, 9 and 12 months. We identified subgroups with distinct symptom burden trajectories using group-based multi-trajectory modelling. We assessed which sociodemographic and clinical characteristics were predictive for high symptom burden trajectories using multivariable logistic regression analysis.

Results: In 841 patients (mean age 65 years [standard deviation 9.8], 50% male), we identified 5 subgroups within the symptom scales and 6 subgroups within the functioning scales. 29% of patients were at risk of both increased symptoms and low functioning, indicating high symptom burden. Younger age, lower educational level, ≥1 comorbidity and hospital admission in the past month were predictive of high symptom burden.

Conclusion: Approximately one-third of patients with stage IV cancer are at risk of high symptom burden. Our study identified distinct patient profiles that can be used to proactively identify those at increased risk. Timely identification of these patients using symptom monitoring allows clinicians to optimize timely and adequate treatment of coexisting symptoms. These findings highlight the importance of personalized approaches in improving health-related quality of life for patients with advanced cancer.

Context: Patients with advanced cancer face evolving trade-offs between life extension, symptom relief, and financial burden. However, little is known about how these priorities change over time and how financial concerns intersect clinical goals near the end of life.

Objectives: To identify distinct longitudinal trajectories of end-of-life care preferences and examine patient characteristics associated with these trajectories.

Methods: We analyzed data from 316 decedents with stage IV solid tumors enrolled in Singapore's COMPASS cohort during their last two years of life. At repeated assessments, patients rated two 9-point trade-offs: 1) life extension versus symptom management, and 2) life extension versus cost containment. Group-based trajectory modeling (GBTM) identified longitudinal patterns. Fixed-effects models assessed within-person changes in preferences over time, and multinomial logistic regressions examined predictors of trajectory membership.

Results: GBTM identified three distinct trajectories for both preference dimensions, with most patients (67.7-76.3%) following balanced trajectories. Fixed-effects analyses revealed dimension-specific within-person changes. Among patients with balanced trajectories, symptom burden and hospice awareness were associated with shifts toward symptom-focused and cost-conscious preferences in both preference dimensions. In the symptom-focused trajectory, prognostic awareness and spiritual well-being were associated with less symptom-focused preferences. In the cost-containment-focused trajectory, hospice awareness was associated with stronger cost-conscious priorities. Age, sex, income level, and marital status predicted trajectory membership.

Conclusion: Goals of care among patients with advanced cancer are largely dynamic, with distinct trajectories reflecting evolving trade-offs between survival, comfort, and cost. Recognizing these patterns can help clinicians anticipate shifting priorities and deliver timely, individualized, and value-concordant care.

Background: Up-to-date knowledge of pain management strategies that provide analgesia and optimize function are central to the toolbox of palliative care and pain providers. To our knowledge, this is the first case report describing a patient with end-of-dosage failure with a buprenorphine patch.

Patient presentation: A 72-year-old male with history of metastatic moderately differentiated adenocarcinoma of unknown primary is admitted to the hospital with cytopenia, abdominal pain and acute kidney injury three weeks after administration of chemotherapy. The patient was transitioned from tramadol 50 mg as needed to buprenorphine patch 5mcg/hr two weeks prior to presentation but described a consistent wearing-off effect by day five of treatment. The patient's buprenorphine patch was exchanged on the evening of day five with resolution of his abdominal pain and improved quality of life markers such as sleep.

Conclusion: This case introduces the first instance in the literature describing end-of-dosage failure with buprenorphine patch and challenges the notion that buprenorphine patches provide seven days of analgesic efficacy for all patients. Ultimately, patients should be screened for premature wearing-off of buprenorphine effect and affected individuals may benefit from a reduced five-day dosing interval to provide more sustained analgesia.

Context: Recognizing and predicting the Syndrome of Imminent Death (SID) is central to end-of-life (EOL) decisions.

Objective: To systematically review the diagnostic/prognostic accuracy of bedside clinical approaches used to recognize or predict the SID (death ≤14 days).

Methods: We searched MEDLINE, Web of Science, and Scopus to 2024. Eligible studies evaluated bedside approaches-individual signs/vitals, composite criteria/scores, clinician probability estimates, and device-based monitoring-against observed death within ≤14 days. Risk of bias was appraised; evidence was synthesized narratively. Certainty was assessed (GRADE-DTA). The protocol was registered (PROSPERO).

Results: Thirteen studies (6,447 patients; 465 clinicians) were included. At ≤48h, clustered signs-confusion, hypotension, low oxygen saturation, death rattle, reduced consciousness-showed positive predictive value (PPV)≈95% and negative predictive value (NPV)≈81% (strong rule-in). At ≤72h, single bedside signs had positive likelihood ratio (LR+)∼9-16. A ≤3-day bedside diagnostic tree reported accuracy=68.3%. In acute/triage cohorts (≤7-14 days), respiratory rate (RR)>28/min and heart rate(HR)≥110/min were associated with higher short-term risk (odds ratio≈12.7 and ≈4.9), amplified by uncontrolled disease/metastasis. Glasgow Prognostic Score(GPS) plus thrombocytopenia achieved specificity>95% and LR+>5 for ≤3 days. The 1-day Surprise Question (SQ) showed sensitivity∼82% and NPV∼91% (≤24h); the 3-day SQ showed sensitivity∼94% and PPV∼54% (≤72h). Nurses outperformed physicians at ≤72h (concordance statistic 0.85 vs 0.68). Continuous, non-wearable monitoring of RR and HR correlated with mortality across 24/48/72h windows. Certainty ranged low to moderate.

Conclusions: Short-horizon recognition of SID is best supported by clustered signs, simple vital-sign cut-offs, and disease context, supplemented by GPS-based composites and 1-/3-day SQ. Prospective external validation with standardized horizons and calibration reporting is needed.

Background: Communicating about death by neurologic criteria (DNC), or brain death, presents complex challenges for multiprofessional providers in pediatrics. The heterogeneity of state-level and institutional brain death policies drives variability in clinical practice patterns, complicating clear and consistent messaging about this nuanced domain. Interprofessional and provider-family communication in brain death cases has been identified as a critical target for interventions, but little is known about multiprofessional clinicians' experiences in communicating about pediatric brain death.

Methods: This qualitative study included semi-structured interviews with physicians, nurses, and social workers at a quaternary children's hospital. We performed inductive coding followed by thematic analysis to identify themes pertaining to clinician approaches to communicating about pediatric brain death, barriers to communication, and strategies to address these challenges.

Results: Twenty-two pediatric clinicians (intensivists, neurologists, registered nurses, clinical social workers) participated. Physicians and non-physicians describe distinct approaches to communicating about pediatric brain death. They identify emotional, cognitive, and relational barriers to communication, including moral distress, inconsistent messaging, prognostic uncertainty, tension between hope and reality, lack of trust, and discrepant values. Provider-generated strategies to address barriers include conducting early, honest conversations, employing consistent messaging, ensuring presence of stakeholders for key conversations, creating emotional distance, and conveying humanity.

Conclusions: Despite widespread recognition of the importance of clear communication in discussions pertaining to brain death, clinicians identify critical barriers to effective communication. Proposed actionable strategies to circumvent barriers prioritize consistent messaging and a humanistic approach. This work informs future communication-based interventions aimed at improving end-of-life care for patients facing a diagnosis of DNC.

Context: Chronic critical illness (CCI) - surviving acute critical illness but requiring prolonged mechanical ventilation - predicts worse one-year outcomes than metastatic non-small cell lung cancer. Although palliative care is routinely integrated into cancer centers, long-term acute care hospitals - to which most patients with CCI are discharged after their acute critical illness - report limited palliative care access. Whether clinician attitudes discourage palliative care involvement in CCI care is unknown.

Objective: To evaluate clinician attitudes towards palliative care for patients with CCI.

Methods: We recruited clinicians from two ventilator-weaning units as part of a larger cross-sectional study. Survey responses included free-text associations with the term 'palliative care' and 4-point Likert scales of agreement with statements about palliative care. We used inductive content analysis, descriptive statistics, and Fisher's exact tests in sensitivity analyses.

Results: 274 of 349 eligible clinicians participated in the survey (response rate 78.5%), representing 11 professions, with similar response rates across sites and professions. Clinicians most often associated 'palliative care' with comfort and support but perceived patients as associating 'palliative care' with death and less treatment. Nearly all clinicians agreed that centers caring for CCI should have palliative care services (N = 261, 97.4%) and they could trust a palliative care clinician to care for their patients with CCI (N = 257, 95.9%).

Conclusion: Clinicians encourage palliative care involvement for CCI. These results emphasize opportunities to integrate palliative care expertise into long-term acute care.

Context: Cancer-related fatigue (CRF) impacts the quality of life of patients with advanced cancer. Systemic corticosteroids are often used empirically to alleviate CRF.

Objectives: We aimed to assess the efficacy and safety of systemic corticosteroids in alleviating CRF in adult patients with advanced cancer.

Methods: We searched Medline (Ovid), the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to 22 October 2024. Randomized controlled trials assessing systemic corticosteroids in adults with CRF who were no longer candidates for curative treatments were included. Primary outcomes were CRF and any adverse events. Data were pooled using a random-effects model and certainty of evidence was assessed using the GRADE approach. The protocol was registered on PROSPERO (CRD42020194253).

Results: Six studies involving 379 participants were included, comprising four placebo-controlled trials and two active-controlled trials. Compared with placebo, use of systemic corticosteroids was associated with reduced CRF (standardized mean difference [SMD] -0.41; 95% confidence interval [CI] -0.82 to -0.00; low certainty), improved global health status (SMD 0.34; 95% CI 0.05 to 0.63; low certainty) and reduced appetite loss (SMD -0.37; 95% CI -0.72 to -0.03; low certainty), without any significant adverse events (risk ratio 1.17; 95% CI, 0.44 to 3.13; low certainty).

Conclusions: Systemic corticosteroids may reduce CRF and may increase global health status and appetite in patients with advanced cancer, with little to no increase in adverse events, albeit with low certainty of all evidence.